Provider Demographics
NPI:1952873051
Name:LEWARS, MARCIA ALTHEA
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:ALTHEA
Last Name:LEWARS
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 1:10241 REGENCY PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-3776
Mailing Address - Country:US
Mailing Address - Phone:727-389-3042
Mailing Address - Fax:
Practice Address - Street 1:10241 REGENCY PARK BLVD
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-3776
Practice Address - Country:US
Practice Address - Phone:727-389-3042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0097758253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0097758Medicaid