Provider Demographics
NPI:1568029270
Name:LEWIS, MARY LEE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LEE
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2153 DEPT 1947
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-0001
Mailing Address - Country:US
Mailing Address - Phone:601-292-4562
Mailing Address - Fax:601-974-6237
Practice Address - Street 1:6250 OLD CANTON RD STE 130
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2946
Practice Address - Country:US
Practice Address - Phone:601-956-7280
Practice Address - Fax:601-977-6244
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4467235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist