Provider Demographics
NPI:1649617275
Name:LEWANDOWSKI, MARA
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:LEWANDOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9016 VINCENT AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-2154
Mailing Address - Country:US
Mailing Address - Phone:952-994-5115
Mailing Address - Fax:952-884-3767
Practice Address - Street 1:9016 VINCENT AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-2154
Practice Address - Country:US
Practice Address - Phone:952-994-5115
Practice Address - Fax:952-884-3767
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3919346-2171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor