Provider Demographics
NPI:1598815565
Name:LEWIS, MICHAEL P (MA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1217
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:859-254-2743
Practice Address - Street 1:1315 GABBARDTOWN RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-9278
Practice Address - Country:US
Practice Address - Phone:859-253-1686
Practice Address - Fax:859-254-2743
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1487101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY0453Medicare ID - Type UnspecifiedMEDICARE