Provider Demographics
NPI:1912182486
Name:LEWIS, SELMA ROSE (PHD)
Entity Type:Individual
Prefix:
First Name:SELMA
Middle Name:ROSE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 LINCOLN AVE
Mailing Address - Street 2:310
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2120
Mailing Address - Country:US
Mailing Address - Phone:415-454-4970
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE
Practice Address - Street 2:310
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2120
Practice Address - Country:US
Practice Address - Phone:415-454-4970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT12274101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor