Healthcare Provider Details

I. General information

NPI: 1912568213
Provider Name (Legal Business Name): MARY LOUISE LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W UNIVERSITY BLVD
MELBOURNE FL
32901-6982
US

IV. Provider business mailing address

150 W UNIVERSITY BLVD
MELBOURNE FL
32901-6982
US

V. Phone/Fax

Practice location:
  • Phone: 321-674-8106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: