Provider Demographics
NPI:1417583279
Name:LEWIS, MALLORY (AMFT)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6276 N 1ST ST STE 103
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5400
Mailing Address - Country:US
Mailing Address - Phone:559-712-4300
Mailing Address - Fax:559-412-7564
Practice Address - Street 1:6276 N 1ST ST STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5400
Practice Address - Country:US
Practice Address - Phone:559-712-4300
Practice Address - Fax:559-412-7564
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118150106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA118150OtherBBS REGISTRATION