Healthcare Provider Details

I. General information

NPI: 1629591136
Provider Name (Legal Business Name): ALISSA THEO LEWIS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALISSA THEO MITCHELL LMFT

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 SPRUCE KEY LN
SLIDELL LA
70461-6115
US

IV. Provider business mailing address

3621 SPRUCE KEY LN
SLIDELL LA
70461-6115
US

V. Phone/Fax

Practice location:
  • Phone: 617-639-7912
  • Fax:
Mailing address:
  • Phone: 617-639-7912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMF6559
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: