Healthcare Provider Details

I. General information

NPI: 1588648257
Provider Name (Legal Business Name): A. RANDY LEWIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CUSHMAN ST STE 4F
FAIRBANKS AK
99701-4665
US

IV. Provider business mailing address

PO BOX 80361
FAIRBANKS AK
99708-0361
US

V. Phone/Fax

Practice location:
  • Phone: 907-457-1128
  • Fax: 907-457-1124
Mailing address:
  • Phone: 907-457-1128
  • Fax: 907-457-1124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number788
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: