MEDICARE: MRS. LYDIA F. LEWIS M.S.

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	LCS16180	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16180	OTHER	CA	CA LIC#

General Provider Information

NPI Number	:	1790719573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYDIA F. LEWIS M.S.

Provider Business Mailing Address
First Line	:	750 STATE ST UNIT 104
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-6032
Country	:	US
Telephone Number	:	619-234-8630
Fax Number	:

Provider Business Practice Location Address
First Line	:	2870 4TH AVE
Second Line	:	SUITE 200
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-6298
Country	:	US
Telephone Number	:	619-234-8630
Fax Number	:	619-297-3908

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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