Provider Demographics
NPI:1457586745
Name:LEWIS, LINDA S (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:S
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:LINDA
Other - Middle Name:S
Other - Last Name:ODENTHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3820 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9059
Mailing Address - Country:US
Mailing Address - Phone:910-228-4666
Mailing Address - Fax:
Practice Address - Street 1:8809 E OAK ISLAND DR
Practice Address - Street 2:
Practice Address - City:OAK ISLAND
Practice Address - State:NC
Practice Address - Zip Code:28465-8369
Practice Address - Country:US
Practice Address - Phone:910-278-5877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5570225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist