Healthcare Provider Details

I. General information

NPI: 1356450225
Provider Name (Legal Business Name): RICHARD B LEWIS III LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 VAUGHAN ST
PORTLAND ME
04102-3204
US

IV. Provider business mailing address

216 VAUGHAN ST
PORTLAND ME
04102-3204
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2221
  • Fax: 207-662-7081
Mailing address:
  • Phone: 207-662-2221
  • Fax: 207-662-7081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC1744
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: