Provider Demographics
NPI:1881043552
Name:LEWIS, PHYLLIS
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CROSSROADS APT 634
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:917-474-3792
Mailing Address - Fax:
Practice Address - Street 1:331 MILAM ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-5353
Practice Address - Country:US
Practice Address - Phone:318-213-0904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor