Provider Demographics
NPI:1538492491
Name:LEWIS, MARK HENRY (LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HENRY
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2127
Mailing Address - Country:US
Mailing Address - Phone:218-739-9084
Mailing Address - Fax:218-739-0518
Practice Address - Street 1:217 N UNION AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2127
Practice Address - Country:US
Practice Address - Phone:218-739-9084
Practice Address - Fax:218-739-0518
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302705101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)