Provider Demographics
NPI:1295979714
Name:LEWIS, ANGELIQUE
Entity type:Individual
Prefix:MS
First Name:ANGELIQUE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N PLANKINTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-1802
Mailing Address - Country:US
Mailing Address - Phone:414-225-1568
Mailing Address - Fax:414-225-1575
Practice Address - Street 1:820 N PLANKINTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-1802
Practice Address - Country:US
Practice Address - Phone:414-225-1568
Practice Address - Fax:414-225-1575
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2880-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical