Provider Demographics
NPI:1437893625
Name:LEWIS, TAMIKA
Entity Type:Individual
Prefix:
First Name:TAMIKA
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 1:110 MOUNTAIN MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-7233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 MOUNTAIN MAPLE LN
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-7233
Practice Address - Country:US
Practice Address - Phone:803-200-1671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7979101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty