Provider Demographics
NPI:1518360171
Name:LEWIS, AMANDA R (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 N GREEN MOUNT RD STE 230
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3494
Mailing Address - Country:US
Mailing Address - Phone:618-334-5571
Mailing Address - Fax:618-551-8955
Practice Address - Street 1:1405 N GREEN MOUNT RD STE 230
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3494
Practice Address - Country:US
Practice Address - Phone:618-334-5571
Practice Address - Fax:618-551-8955
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0182451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical