Provider Demographics
NPI:1700501319
Name:LEWIS, ALICIAN REQUELL (PT)
Entity Type:Individual
Prefix:
First Name:ALICIAN
Middle Name:REQUELL
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15135 MEMORIAL DR APT 8310
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-4312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4970 BARKSDALE BLVD STE 900
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4677
Practice Address - Country:US
Practice Address - Phone:318-747-8892
Practice Address - Fax:318-747-8893
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2024-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1364824225100000X
LACP028237T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist