Provider Demographics
NPI:1629514393
Name:SHACK, LEWINFRED A (MDIV, LMT)
Entity Type:Individual
Prefix:
First Name:LEWINFRED
Middle Name:A
Last Name:SHACK
Suffix:
Gender:M
Credentials:MDIV, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 KIRBY RD STE 116
Mailing Address - Street 2:PMB 121
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8245
Mailing Address - Country:US
Mailing Address - Phone:901-633-6259
Mailing Address - Fax:
Practice Address - Street 1:7622 POPLAR PIKE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-5941
Practice Address - Country:US
Practice Address - Phone:901-633-6259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4952225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist