Provider Demographics
NPI:1639285620
Name:LEWIS, MARCELLA M (LCSW-R)
Entity type:Individual
Prefix:MS
First Name:MARCELLA
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-3744
Mailing Address - Country:US
Mailing Address - Phone:315-732-7615
Mailing Address - Fax:317-724-4700
Practice Address - Street 1:1155 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-3744
Practice Address - Country:US
Practice Address - Phone:315-732-7615
Practice Address - Fax:317-724-4700
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0406941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7491844002OtherGHI
NY01742685Medicaid
NY615452OtherMVP
NY01742685Medicaid