Healthcare Provider Details

I. General information

NPI: 1699586677
Provider Name (Legal Business Name): MARYANN LEWIS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N COLLEGE RD
TWIN FALLS ID
83301-3484
US

IV. Provider business mailing address

518 CLOVER AVE
TWIN FALLS ID
83301-7601
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-9100
  • Fax:
Mailing address:
  • Phone: 951-750-9867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2471044
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: