Healthcare Provider Details

I. General information

NPI: 1043565419
Provider Name (Legal Business Name): MR. MELVILLE LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E 12TH ST SUITE 259
OAKLAND CA
94601
US

IV. Provider business mailing address

5275 CLAREMONT AVE
OAKLAND CA
94618-1032
US

V. Phone/Fax

Practice location:
  • Phone: 530-400-6574
  • Fax:
Mailing address:
  • Phone: 510-428-3885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: