Provider Demographics
NPI:1437864576
Name:LEWIS, CECELYN
Entity Type:Individual
Prefix:
First Name:CECELYN
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 1:1461 73RD AVE NE APT 204
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3719
Mailing Address - Country:US
Mailing Address - Phone:763-400-1499
Mailing Address - Fax:
Practice Address - Street 1:3007 HARBOR LN N STE 1200
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5138
Practice Address - Country:US
Practice Address - Phone:612-445-8314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician