Provider Demographics
NPI:1932304276
Name:LEWIS, JOHN KELLUM (LMFT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KELLUM
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 N MARENGO AVE
Mailing Address - Street 2:STE. 205
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1764
Mailing Address - Country:US
Mailing Address - Phone:323-860-8782
Mailing Address - Fax:
Practice Address - Street 1:95 N MARENGO AVE
Practice Address - Street 2:STE. 205
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1764
Practice Address - Country:US
Practice Address - Phone:323-860-8782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42989106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist