Provider Demographics
NPI:1336928753
Name:LEWIS, KENYAN X
Entity Type:Individual
Prefix:
First Name:KENYAN
Middle Name:X
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 N FEDERAL HWY STE 209
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-6722
Mailing Address - Country:US
Mailing Address - Phone:195-486-6143
Mailing Address - Fax:
Practice Address - Street 1:4291 NW 45TH ST
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-3870
Practice Address - Country:US
Practice Address - Phone:754-214-7687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-299959106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician