Provider Demographics
NPI:1811132848
Name:LEWIS, MARILYN RUTH
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:RUTH
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 1:21 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-1012
Mailing Address - Country:US
Mailing Address - Phone:636-296-6206
Mailing Address - Fax:
Practice Address - Street 1:21 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-1012
Practice Address - Country:US
Practice Address - Phone:636-296-6206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002106101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional