Provider Demographics
NPI:1639279177
Name:LEWIS, GERALD C (CNS, BC)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:C
Last Name:LEWIS
Suffix:
Gender:M
Credentials:CNS, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9120 CONNECTICUT ST STE A
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7015
Mailing Address - Country:US
Mailing Address - Phone:219-793-1233
Mailing Address - Fax:
Practice Address - Street 1:9120 CONNECTICUT ST STE A
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7015
Practice Address - Country:US
Practice Address - Phone:219-793-1233
Practice Address - Fax:219-793-1244
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000167364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01054054OtherRR MEDICARE
INP01054054OtherRR MEDICARE
IN000000746666OtherBCBS BMG BEHAVIORAL HEALTH
INP01054054OtherRR MEDICARE
INM400061494Medicare PIN