MEDICARE: MARK HENRY LEWIS L.A.D.C.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	302705	MN

General Provider Information

NPI Number	:	1538492491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK HENRY LEWIS L.A.D.C.

Provider Business Mailing Address
First Line	:	217 N UNION AVE
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-2127
Country	:	US
Telephone Number	:	218-739-9084
Fax Number	:	218-739-0518

Provider Business Practice Location Address
First Line	:	217 N UNION AVE
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-2127
Country	:	US
Telephone Number	:	218-739-9084
Fax Number	:	218-739-0518

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

Provider Enumeration Date	:	09/10/2009
Last Update Date	:	09/10/2009

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