Healthcare Provider Details

I. General information

NPI: 1538779301
Provider Name (Legal Business Name): MARC GRAYSON LEWIS RN, BSN, CARN, QMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 SE 3RD ST
BEND OR
97702-1754
US

IV. Provider business mailing address

2711 NW RAINBOW RIDGE DR
BEND OR
97703-8722
US

V. Phone/Fax

Practice location:
  • Phone: 541-668-9070
  • Fax:
Mailing address:
  • Phone: 808-345-6027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22-QMHPC-001160
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201805080RN
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: