Provider Demographics
NPI:1629204649
Name:LEWIS, KENNETH ROBERT (CP00004923)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROBERT
Last Name:LEWIS
Suffix:
Gender:M
Credentials:CP00004923
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9412 W 5TH PL
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-9603
Mailing Address - Country:US
Mailing Address - Phone:509-396-7510
Mailing Address - Fax:
Practice Address - Street 1:9412 W 5TH PL
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-9603
Practice Address - Country:US
Practice Address - Phone:509-396-7510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004923171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator