Provider Demographics
NPI:1609062256
Name:LEWIS, CARLTON DESHAWN
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:DESHAWN
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 1:414 MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-7354
Mailing Address - Country:US
Mailing Address - Phone:505-762-9000
Mailing Address - Fax:
Practice Address - Street 1:414 MITCHELL ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-7354
Practice Address - Country:US
Practice Address - Phone:505-762-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0106271101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health