Provider Demographics
NPI:1346518982
Name:LEWIS, KHADIJAH A (PT)
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:A
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 W LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-8664
Mailing Address - Country:US
Mailing Address - Phone:773-807-0487
Mailing Address - Fax:
Practice Address - Street 1:3506 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1654
Practice Address - Country:US
Practice Address - Phone:262-653-3814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-10
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11149-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist