Provider Demographics
NPI:1871630160
Name:LEWIS, GARY R (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8686 CAPRICORN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-1851
Mailing Address - Country:US
Mailing Address - Phone:858-695-9535
Mailing Address - Fax:858-549-7057
Practice Address - Street 1:8686 CAPRICORN WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-1851
Practice Address - Country:US
Practice Address - Phone:858-695-9535
Practice Address - Fax:858-549-7057
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 14349103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical