Provider Demographics
NPI:1619064649
Name:LEWIS, MARY ANNE (EDD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 S COLUMBIA AVE
Mailing Address - Street 2:#580
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-3519
Mailing Address - Country:US
Mailing Address - Phone:918-747-9292
Mailing Address - Fax:918-747-9293
Practice Address - Street 1:2121 S COLUMBIA AVE
Practice Address - Street 2:#580
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3519
Practice Address - Country:US
Practice Address - Phone:918-747-9292
Practice Address - Fax:918-747-9293
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK591103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist