Provider Demographics
NPI:1639601057
Name:LEWIS, MACHELL (LMT)
Entity Type:Individual
Prefix:
First Name:MACHELL
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:MACHELL
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:295 S CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1287
Mailing Address - Country:US
Mailing Address - Phone:801-213-3779
Mailing Address - Fax:
Practice Address - Street 1:295 S CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1287
Practice Address - Country:US
Practice Address - Phone:801-213-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114774-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist