Provider Demographics
NPI:1790719573
Name:LEWIS, LYDIA F (MS)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:F
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 STATE ST UNIT 104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6032
Mailing Address - Country:US
Mailing Address - Phone:619-234-8630
Mailing Address - Fax:
Practice Address - Street 1:2870 4TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6298
Practice Address - Country:US
Practice Address - Phone:619-234-8630
Practice Address - Fax:619-297-3908
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS161801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16180OtherCA LIC#