Provider Demographics
NPI:1336746338
Name:LEWIS, MONTRELLE LATWAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:MONTRELLE
Middle Name:LATWAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7704 BROWNS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-5644
Mailing Address - Country:US
Mailing Address - Phone:843-325-5660
Mailing Address - Fax:
Practice Address - Street 1:2199 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-6409
Practice Address - Country:US
Practice Address - Phone:843-527-6835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-03
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3566225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant