Healthcare Provider Details

I. General information

NPI: 1902516552
Provider Name (Legal Business Name): ISIDORA IZZY LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 ROUTE 18 STE 3000
EAST BRUNSWICK NJ
08816-1440
US

IV. Provider business mailing address

197 ROUTE 18 STE 3000
EAST BRUNSWICK NJ
08816-1440
US

V. Phone/Fax

Practice location:
  • Phone: 888-571-1521
  • Fax: 732-626-6298
Mailing address:
  • Phone:
  • Fax: 732-626-6298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberCERTIFICATE
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: