Healthcare Provider Details

I. General information

NPI: 1104190834
Provider Name (Legal Business Name): MR. BRANDON SCOTT LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 S GLOSTER ST
TUPELO MS
38801-6510
US

IV. Provider business mailing address

1502 S GLOSTER ST
TUPELO MS
38801-6510
US

V. Phone/Fax

Practice location:
  • Phone: 662-844-0047
  • Fax: 662-844-0780
Mailing address:
  • Phone: 662-844-0047
  • Fax: 662-844-0780

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: