Provider Demographics
NPI:1457923104
Name:LEWIS, DOUGLAS EDWARD JR (PSYD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1230 BALD RIDGE MARINA RD STE 800
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7536
Mailing Address - Country:US
Mailing Address - Phone:434-548-3656
Mailing Address - Fax:
Practice Address - Street 1:2550 BLACKMON DR APT 4214
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6232
Practice Address - Country:US
Practice Address - Phone:434-548-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004426103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist