Provider Demographics
NPI:1568712701
Name:LEWIS, PHILLIP DERRELL (PHD, CRC, LADC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:DERRELL
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD, CRC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9244 FREEDOM RD UNIT 838
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-2198
Mailing Address - Country:US
Mailing Address - Phone:901-289-5006
Mailing Address - Fax:918-877-8101
Practice Address - Street 1:1301 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-4235
Practice Address - Country:US
Practice Address - Phone:405-424-0007
Practice Address - Fax:405-424-6507
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)