Provider Demographics
NPI:1851177158
Name:LEWIS, CODY-RYAN
Entity Type:Individual
Prefix:
First Name:CODY-RYAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 EAST 5770 SOUTH
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-301-8004
Mailing Address - Fax:
Practice Address - Street 1:323 EAST 5770 SOUTH
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-301-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744R1102X
ZZ2545005702106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No1744R1102XOther Service ProvidersSpecialistResearch Study