Provider Demographics
NPI:1467846303
Name:LEWIS, CAROL (MFC 53526)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MFC 53526
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12522 MOORPARK ST STE 108
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-1355
Mailing Address - Country:US
Mailing Address - Phone:818-877-5115
Mailing Address - Fax:
Practice Address - Street 1:12522 MOORPARK ST STE 108
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-1355
Practice Address - Country:US
Practice Address - Phone:818-877-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 53526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist