Provider Demographics
NPI:1255127098
Name:RIVERA LEWIS, KELLY MARIE (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:RIVERA LEWIS
Suffix:
Gender:
Credentials:LMFT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 MAPLE HILLS DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4420
Mailing Address - Country:US
Mailing Address - Phone:614-306-0694
Mailing Address - Fax:
Practice Address - Street 1:112 CANDLEWOOD CT
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2653
Practice Address - Country:US
Practice Address - Phone:434-258-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717002392106H00000X
NC20725106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist