Provider Demographics
NPI:1750682134
Name:LEWIS, SUSANNA (LCAS, LPCA)
Entity Type:Individual
Prefix:MS
First Name:SUSANNA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LCAS, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 ROLLERTON RD
Mailing Address - Street 2:APT.106
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1057
Mailing Address - Country:US
Mailing Address - Phone:252-531-7822
Mailing Address - Fax:
Practice Address - Street 1:708 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4548
Practice Address - Country:US
Practice Address - Phone:252-531-7822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1688101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101Y00000XMedicaid