Provider Demographics
NPI:1861656662
Name:LEWIS, KATHERINE E (PH D)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E GENESEE ST
Mailing Address - Street 2:SUITE 217
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3130
Mailing Address - Country:US
Mailing Address - Phone:315-422-0300
Mailing Address - Fax:315-479-8455
Practice Address - Street 1:600 E GENESEE ST
Practice Address - Street 2:SUITE 217
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3130
Practice Address - Country:US
Practice Address - Phone:315-422-0300
Practice Address - Fax:315-479-8455
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03030577Medicaid
NY03030577Medicaid