Provider Demographics
NPI:1629321310
Name:CLEWIS, LAQUITA (LCDC)
Entity Type:Individual
Prefix:
First Name:LAQUITA
Middle Name:
Last Name:CLEWIS
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N PANAMA ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77864-1546
Mailing Address - Country:US
Mailing Address - Phone:936-349-0589
Mailing Address - Fax:866-562-2811
Practice Address - Street 1:207 N PANAMA ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TX
Practice Address - Zip Code:77864-1546
Practice Address - Country:US
Practice Address - Phone:936-349-0589
Practice Address - Fax:866-562-2811
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9611101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)