Provider Demographics
NPI:1992376966
Name:LEWIS, KERRY BRYANT (PASTOR)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:BRYANT
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PASTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-3700
Mailing Address - Country:US
Mailing Address - Phone:323-955-6253
Mailing Address - Fax:
Practice Address - Street 1:503 UNION DR APT 310
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1841
Practice Address - Country:US
Practice Address - Phone:213-568-3509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95444626G80154Medicaid