Provider Demographics
NPI:1730646217
Name:LEWIS, MARLENE P
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:P
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5245 RAMSEY WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-2124
Mailing Address - Country:US
Mailing Address - Phone:239-691-6482
Mailing Address - Fax:888-391-5328
Practice Address - Street 1:2402 DEL RAY PL
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-4357
Practice Address - Country:US
Practice Address - Phone:954-729-8153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty