Provider Demographics
NPI:1982340345
Name:LEWIS, MARY JANE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 N FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:ELOY
Mailing Address - State:AZ
Mailing Address - Zip Code:85131-1181
Mailing Address - Country:US
Mailing Address - Phone:910-352-9624
Mailing Address - Fax:
Practice Address - Street 1:1410 N FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85131-1181
Practice Address - Country:US
Practice Address - Phone:910-352-9624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9945-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical