MEDICARE: ANDREA MILES LEWIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904001384	VA

General Provider Information

NPI Number	:	1326365750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA MILES LEWIS

Provider Business Mailing Address
First Line	:	4646 PRINCESS ANNE RD
Second Line	:	SUITE 102
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-6464
Country	:	US
Telephone Number	:	757-213-4490
Fax Number	:	757-213-4491

Provider Business Practice Location Address
First Line	:	4646 PRINCESS ANNE RD
Second Line	:	SUITE 102
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-6464
Country	:	US
Telephone Number	:	757-213-4490
Fax Number	:	757-213-4491

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2010
Last Update Date	:	04/25/2010

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