Provider Demographics
NPI:1518645464
Name:LEWIS, MADELYN P
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:P
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37560 SIERRA HWY # 829
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-9366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36722 45TH ST E
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93552-5833
Practice Address - Country:US
Practice Address - Phone:661-227-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1333380119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)