Provider Demographics
NPI:1417241407
Name:BOATNER, LEWIS
Entity Type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:
Last Name:BOATNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010A SHANNAHAN DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-1170
Mailing Address - Country:US
Mailing Address - Phone:313-461-4984
Mailing Address - Fax:
Practice Address - Street 1:201 UFFELMAN DR STE F
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-2970
Practice Address - Country:US
Practice Address - Phone:931-920-7333
Practice Address - Fax:931-920-7331
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health