Provider Demographics
NPI:1184950693
Name:LEWIS, KRYSTAL MEREDITH (SUPERVISED LADC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MEREDITH
Last Name:LEWIS
Suffix:
Gender:F
Credentials:SUPERVISED LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SW 69TH ST APT D
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-6724
Mailing Address - Country:US
Mailing Address - Phone:580-264-3090
Mailing Address - Fax:
Practice Address - Street 1:605 W GORE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3732
Practice Address - Country:US
Practice Address - Phone:580-250-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100734740AMedicaid