Healthcare Provider Details

I. General information

NPI: 1184714982
Provider Name (Legal Business Name): MARCELLA A LEWIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2375 MEMPHIS ST SUITE 208
HERNANDO MS
38632-1756
US

IV. Provider business mailing address

2375 MEMPHIS ST SUITE 208
HERNANDO MS
38632-1756
US

V. Phone/Fax

Practice location:
  • Phone: 901-230-0622
  • Fax: 662-449-0422
Mailing address:
  • Phone: 901-230-0622
  • Fax: 662-449-0422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number00688
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7256
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: