Provider Demographics
NPI:1336786680
Name:LEWIS, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
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:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-0056
Mailing Address - Country:US
Mailing Address - Phone:757-805-0339
Mailing Address - Fax:
Practice Address - Street 1:20079 STONE OAK PKWY STE 1275
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-6983
Practice Address - Country:US
Practice Address - Phone:210-481-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82727101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional