Provider Demographics
NPI:1700322047
Name:LEWIS, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:DEARFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 BOBOLINK RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1503
Mailing Address - Country:US
Mailing Address - Phone:606-471-0267
Mailing Address - Fax:
Practice Address - Street 1:1402 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-1611
Practice Address - Country:US
Practice Address - Phone:304-412-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03191225200000X
NVA0946225200000X
OR09380225200000X
KY260047225X00000X
WV2091225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV14628430OtherCAQH