Provider Demographics
NPI:1760463590
Name:LEWIS, VERNON M (PHD,LP)
Entity Type:Individual
Prefix:DR
First Name:VERNON
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-1911
Mailing Address - Country:US
Mailing Address - Phone:507-433-6482
Mailing Address - Fax:507-433-0097
Practice Address - Street 1:1403 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-1911
Practice Address - Country:US
Practice Address - Phone:507-433-6482
Practice Address - Fax:507-433-0097
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1533103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist