Provider Demographics
NPI:1245896455
Name:LEWIS, KHEDEDRA RENEE (SLP)
Entity type:Individual
Prefix:MS
First Name:KHEDEDRA
Middle Name:RENEE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E BELLEVUE DR APT 231
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3106
Mailing Address - Country:US
Mailing Address - Phone:757-660-2784
Mailing Address - Fax:
Practice Address - Street 1:1575 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-2675
Practice Address - Country:US
Practice Address - Phone:626-317-0179
Practice Address - Fax:626-798-1647
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25904235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist