Provider Demographics
NPI:1801125646
Name:LEWIS, MELINDA GAYE (LPA)
Entity type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:GAYE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 E HWY 377 STE 110169
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1456
Mailing Address - Country:US
Mailing Address - Phone:817-559-7989
Mailing Address - Fax:
Practice Address - Street 1:1104 HEREFORD ST
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043
Practice Address - Country:US
Practice Address - Phone:682-302-4597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72023101YP2500X
TX30157103TS0200X
TX14339103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool