Provider Demographics
NPI:1972645489
Name:LEWIS, JOHN RICHARD (LBSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RICHARD
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LBSW
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 20074
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77720-0074
Mailing Address - Country:US
Mailing Address - Phone:409-861-1708
Mailing Address - Fax:409-861-1923
Practice Address - Street 1:15211 PARK ROW APT 527
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-4142
Practice Address - Country:US
Practice Address - Phone:409-861-1708
Practice Address - Fax:409-861-1923
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26309104100000X, 251B00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX066052403Medicaid