Provider Demographics
NPI:1558070524
Name:LEWIS SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:LEWIS SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:KETURAH
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:BS PSYCHOLOGY
Authorized Official - Phone:434-609-5600
Mailing Address - Street 1:1015 SUNSET VIEW CT
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2127
Mailing Address - Country:US
Mailing Address - Phone:434-609-5600
Mailing Address - Fax:
Practice Address - Street 1:1015 SUNSET VIEW CT
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-2127
Practice Address - Country:US
Practice Address - Phone:434-609-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-18
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4077-001Medicaid