Healthcare Provider Details

I. General information

NPI: 1174835029
Provider Name (Legal Business Name): VONNIE LEE LEWIS LPC MENTAL HEALTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N 20TH ST
PHILOMATH OR
97370-9535
US

IV. Provider business mailing address

PO BOX 455
PHILOMATH OR
97370-0455
US

V. Phone/Fax

Practice location:
  • Phone: 541-368-4313
  • Fax: 541-929-4967
Mailing address:
  • Phone: 541-368-4313
  • Fax: 541-929-4967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC0069
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC C0069
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: