Healthcare Provider Details

I. General information

NPI: 1275988016
Provider Name (Legal Business Name): MATTHEW LEWIS CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 VICTORY PKWY
CINCINNATI OH
45206-1711
US

IV. Provider business mailing address

2602 VICTORY PKWY
CINCINNATI OH
45206-1711
US

V. Phone/Fax

Practice location:
  • Phone: 513-221-4673
  • Fax: 513-221-2343
Mailing address:
  • Phone: 513-221-4673
  • Fax: 513-221-2343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number151877
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: