Provider Demographics
NPI:1801620125
Name:LEWIS, ANTIONETTE (RBT)
Entity type:Individual
Prefix:MS
First Name:ANTIONETTE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7560 RAMBLING VALE
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-6605
Mailing Address - Country:US
Mailing Address - Phone:770-858-3181
Mailing Address - Fax:
Practice Address - Street 1:2100 WESTSHORE DR STE 117
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9277
Practice Address - Country:US
Practice Address - Phone:770-878-3175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-221530171W00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171W00000XOther Service ProvidersContractor