Provider Demographics
NPI:1689977084
Name:LEWIS, CHARLA (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 GULFTON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-1107
Mailing Address - Country:US
Mailing Address - Phone:713-457-4372
Mailing Address - Fax:469-294-9175
Practice Address - Street 1:3025 E RENNER RD STE 303
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-3580
Practice Address - Country:US
Practice Address - Phone:713-457-4372
Practice Address - Fax:713-457-0945
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04586103T00000X
DC1000544103T00000X
TX38413103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD037904200Medicaid
1A6905OtherMEDICARE
TX408966601Medicaid