Provider Demographics
NPI:1083237598
Name:LEWIS, KHADIJAH JEAN-MARIE
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:JEAN-MARIE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KHADIJAH
Other - Middle Name:
Other - Last Name:BYRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-366-1264
Mailing Address - Fax:
Practice Address - Street 1:6324 FAIRVIEW RD STE 460
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3374
Practice Address - Country:US
Practice Address - Phone:980-302-8611
Practice Address - Fax:980-302-8624
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00268106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty