Provider Demographics
NPI:1649670613
Name:LEWIS, KANDYCE (LMT)
Entity type:Individual
Prefix:
First Name:KANDYCE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 CRESWELL RD APT 122
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-4710
Mailing Address - Country:US
Mailing Address - Phone:318-820-9257
Mailing Address - Fax:
Practice Address - Street 1:1534 ELIZABETH AVE
Practice Address - Street 2:#206
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4516
Practice Address - Country:US
Practice Address - Phone:318-820-9257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2486225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist