Provider Demographics
NPI:1659635035
Name:LEWIS, MARY CLEARY (MA, CERT PSYA)
Entity Type:Individual
Prefix:MRS
First Name:MARY CLEARY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA, CERT PSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05255-0602
Mailing Address - Country:US
Mailing Address - Phone:802-236-3389
Mailing Address - Fax:
Practice Address - Street 1:20 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BELLOWS FALLS
Practice Address - State:VT
Practice Address - Zip Code:05101-1515
Practice Address - Country:US
Practice Address - Phone:802-236-3389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT098.0072215102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst