Provider Demographics
NPI:1578961322
Name:LEWIS, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
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 1:443 W WRIGHTWOOD AVE
Mailing Address - Street 2:APT 805
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1755
Mailing Address - Country:US
Mailing Address - Phone:631-662-6693
Mailing Address - Fax:
Practice Address - Street 1:137 N OAK PARK AVE
Practice Address - Street 2:SUITE 218
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1344
Practice Address - Country:US
Practice Address - Phone:708-386-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008975103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical