Provider Demographics
NPI:1295400570
Name:LEWELLYAN, DEATRICE MARIE
Entity Type:Individual
Prefix:
First Name:DEATRICE
Middle Name:MARIE
Last Name:LEWELLYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 W CORCORAN
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644
Mailing Address - Country:US
Mailing Address - Phone:312-636-2624
Mailing Address - Fax:
Practice Address - Street 1:5645 W CORCORAN
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644
Practice Address - Country:US
Practice Address - Phone:312-636-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health