Provider Demographics
NPI:1760655849
Name:MILLSAP, LEWIS JOHN III (MA)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:JOHN
Last Name:MILLSAP
Suffix:III
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-2662
Mailing Address - Country:US
Mailing Address - Phone:765-472-1931
Mailing Address - Fax:765-472-1945
Practice Address - Street 1:655 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2662
Practice Address - Country:US
Practice Address - Phone:765-472-1931
Practice Address - Fax:765-472-1945
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN00270101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00270OtherICAC