Provider Demographics
NPI:1508352873
Name:LEWIS, MIQUEL ANTONIO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIQUEL
Middle Name:ANTONIO
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10044 S BELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1904
Mailing Address - Country:US
Mailing Address - Phone:177-341-8336
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE STE 1125
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3738
Practice Address - Country:US
Practice Address - Phone:177-341-8336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005207101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional