Provider Demographics
NPI:1508887233
Name:LEWIS, MICKEY L (LMFT/CADC)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LMFT/CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215C BLUEGRASS ROAD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134
Mailing Address - Country:US
Mailing Address - Phone:270-253-3722
Mailing Address - Fax:270-253-3768
Practice Address - Street 1:215 BLUEGRASS RD
Practice Address - Street 2:UNIT C
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2459
Practice Address - Country:US
Practice Address - Phone:270-253-3722
Practice Address - Fax:270-253-3768
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0060101YA0400X
KY0348106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid