Provider Demographics
NPI:1780138834
Name:LEWIS, CODY S
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:S
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 S BUSEY AVE
Mailing Address - Street 2:#1
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-4092
Mailing Address - Country:US
Mailing Address - Phone:314-605-8942
Mailing Address - Fax:
Practice Address - Street 1:602 S BUSEY AVE
Practice Address - Street 2:#1
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-4092
Practice Address - Country:US
Practice Address - Phone:314-605-8942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.101685104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker