Provider Demographics
NPI:1780399964
Name:LEWIS, TAMMARA LETICIA
Entity type:Individual
Prefix:
First Name:TAMMARA
Middle Name:LETICIA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 NW 187TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4013
Mailing Address - Country:US
Mailing Address - Phone:786-635-7571
Mailing Address - Fax:
Practice Address - Street 1:4330 W BROWARD BLVD STE I
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-3753
Practice Address - Country:US
Practice Address - Phone:786-635-7571
Practice Address - Fax:877-341-1196
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21793101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health