Provider Demographics
NPI:1629673314
Name:LEWIS, TIMOTHY NATHAN
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:NATHAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 N PERRYVILLE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6225
Mailing Address - Country:US
Mailing Address - Phone:779-368-0060
Mailing Address - Fax:815-977-4892
Practice Address - Street 1:695 N PERRYVILLE RD STE 4
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6225
Practice Address - Country:US
Practice Address - Phone:779-368-0060
Practice Address - Fax:815-977-4892
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178016413101YP2500X
IL180015275101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional