Provider Demographics
NPI:1417413485
Name:LEWIS, TAMIKA NICOLE
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:NICOLE
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 1:16300 WAUSAU AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2158
Mailing Address - Country:US
Mailing Address - Phone:708-777-9311
Mailing Address - Fax:
Practice Address - Street 1:20013 LAKEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60411-1515
Practice Address - Country:US
Practice Address - Phone:708-965-2278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003876224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty