Provider Demographics
NPI:1912366139
Name:LEWIS, GLENDA LEE (CADC II, CAGC II, CA)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:LEE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:CADC II, CAGC II, CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-672-2691
Mailing Address - Fax:541-673-5642
Practice Address - Street 1:418 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97470-2006
Practice Address - Country:US
Practice Address - Phone:541-474-1033
Practice Address - Fax:541-474-0770
Is Sole Proprietor?:No
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORG07-03-05101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)