Provider Demographics
NPI:1831179563
Name:LEWIS, ANGIE D (MA)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:D
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:D
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:4090 W VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52411-7845
Mailing Address - Country:US
Mailing Address - Phone:319-929-5668
Mailing Address - Fax:
Practice Address - Street 1:1560 BOYSON RD STE B
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2385
Practice Address - Country:US
Practice Address - Phone:319-929-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA040075101YA0400X
IA00853101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)