Provider Demographics
NPI:1326382359
Name:LEWIS, TIARA R (BA)
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:R
Last Name:LEWIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 PEQUOT AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4440
Mailing Address - Country:US
Mailing Address - Phone:860-639-9279
Mailing Address - Fax:
Practice Address - Street 1:255 HEMPSTEAD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6204
Practice Address - Country:US
Practice Address - Phone:860-443-2896
Practice Address - Fax:860-442-5909
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker