Provider Demographics
NPI:1790125888
Name:LEWIS, EBONY M
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:M
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 1:4045 SPENCER ST
Mailing Address - Street 2:A45
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-9304
Mailing Address - Country:US
Mailing Address - Phone:702-752-6463
Mailing Address - Fax:
Practice Address - Street 1:4045 SPENCER ST
Practice Address - Street 2:A45
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-9304
Practice Address - Country:US
Practice Address - Phone:702-752-6463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner