Healthcare Provider Details

I. General information

NPI: 1124048871
Provider Name (Legal Business Name): ANDRE L LEWIS L.C.S.W
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 W 5TH AVE
CROSSETT AR
71635-2500
US

IV. Provider business mailing address

790 ROBERTS DR
MONTICELLO AR
71655-5723
US

V. Phone/Fax

Practice location:
  • Phone: 870-364-6471
  • Fax: 870-364-9753
Mailing address:
  • Phone: 870-364-6471
  • Fax: 870-364-9753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2170-C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: