Provider Demographics
NPI:1598249583
Name:LEWIS, THOMAS VERNON
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:VERNON
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 MORGAN WAY APT 208
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-5154
Mailing Address - Country:US
Mailing Address - Phone:304-276-6508
Mailing Address - Fax:
Practice Address - Street 1:2500 POLO RIDGE CT
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3950
Practice Address - Country:US
Practice Address - Phone:336-722-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11174225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist