Provider Demographics
NPI:1619056884
Name:LEWIS, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
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:N2943 OPELT AVE
Mailing Address - Street 2:
Mailing Address - City:NEILLSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54456-7210
Mailing Address - Country:US
Mailing Address - Phone:715-743-3565
Mailing Address - Fax:
Practice Address - Street 1:702 E WILLOW DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WI
Practice Address - Zip Code:54479-9344
Practice Address - Country:US
Practice Address - Phone:715-659-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1658OtherLICENSE#