Provider Demographics
NPI:1649798083
Name:LEWIS, BRIAN JOSEPH (LMT, NBCHT, PT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LMT, NBCHT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-7064
Mailing Address - Country:US
Mailing Address - Phone:386-719-8887
Mailing Address - Fax:386-438-8732
Practice Address - Street 1:322 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-7064
Practice Address - Country:US
Practice Address - Phone:386-719-8887
Practice Address - Fax:386-438-8732
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA60365225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist