Provider Demographics
NPI:1790219541
Name:LEWIS, TRACY LEWIS (LPC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEWIS
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5511 SE HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3367
Mailing Address - Country:US
Mailing Address - Phone:503-517-1895
Mailing Address - Fax:
Practice Address - Street 1:5511 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3367
Practice Address - Country:US
Practice Address - Phone:503-517-1895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4407101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional