Provider Demographics
NPI:1477877629
Name:LEWIS, DEDRA Y (COTA/L)
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:Y
Last Name:LEWIS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12650 SHOREWOOD LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-0518
Mailing Address - Country:US
Mailing Address - Phone:760-947-4069
Mailing Address - Fax:
Practice Address - Street 1:12650 SHOREWOOD LN
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-0518
Practice Address - Country:US
Practice Address - Phone:760-947-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant