Healthcare Provider Details

I. General information

NPI: 1770356875
Provider Name (Legal Business Name): MR. ELIJAH JUDE LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1634 RYAN ST
LAKE CHARLES LA
70601-5949
US

IV. Provider business mailing address

1634 RYAN ST
LAKE CHARLES LA
70601-5949
US

V. Phone/Fax

Practice location:
  • Phone: 337-602-6391
  • Fax: 337-602-6392
Mailing address:
  • Phone: 337-602-6391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: