Healthcare Provider Details

I. General information

NPI: 1326382359
Provider Name (Legal Business Name): TIARA R LEWIS BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 HEMPSTEAD ST
NEW LONDON CT
06320-6204
US

IV. Provider business mailing address

395 PEQUOT AVE APT 4
NEW LONDON CT
06320-4440
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-2896
  • Fax: 860-442-5909
Mailing address:
  • Phone: 860-639-9279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: