Provider Demographics
NPI:1336858315
Name:LEWIS, LAMONT (MDIV)
Entity Type:Individual
Prefix:PROF
First Name:LAMONT
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 E 44TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-3502
Mailing Address - Country:US
Mailing Address - Phone:847-312-6675
Mailing Address - Fax:
Practice Address - Street 1:828 E 44TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3502
Practice Address - Country:US
Practice Address - Phone:847-312-6675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner