Provider Demographics
NPI:1689885451
Name:LEWIS, DAVID R (MSSW, LICSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MSSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-4476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:464 S SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:WI
Practice Address - Zip Code:54612-1401
Practice Address - Country:US
Practice Address - Phone:608-323-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6892-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40907100Medicaid