Healthcare Provider Details

I. General information

NPI: 1689404279
Provider Name (Legal Business Name): MS. BA'RAN STACEY LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

695 TRUMAN HWY
BOSTON MA
02136-3552
US

IV. Provider business mailing address

6 ADAMS ST
HYDE PARK MA
02136-2102
US

V. Phone/Fax

Practice location:
  • Phone: 888-763-7272
  • Fax:
Mailing address:
  • Phone: 617-971-6794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: