Provider Demographics
NPI:1205472370
Name:LEWIS, AMANDA KAY (LPC, MA-CHMC, CADC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LPC, MA-CHMC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 TRIUMPH DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-6028
Mailing Address - Country:US
Mailing Address - Phone:208-995-3203
Mailing Address - Fax:
Practice Address - Street 1:1407 W MCMILLAN RD STE 120
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5168
Practice Address - Country:US
Practice Address - Phone:208-315-6717
Practice Address - Fax:208-315-6718
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11506101YA0400X
IDLPC-7988101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty