Provider Demographics
NPI:1386037513
Name:LEWIS, LOLLY
Entity Type:Individual
Prefix:
First Name:LOLLY
Middle Name:
Last Name:LEWIS
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 1:1023 BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1516
Mailing Address - Country:US
Mailing Address - Phone:708-990-2190
Mailing Address - Fax:
Practice Address - Street 1:1023 BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1516
Practice Address - Country:US
Practice Address - Phone:708-990-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health