Healthcare Provider Details

I. General information

NPI: 1053847251
Provider Name (Legal Business Name): NICOLE BASHAN LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 3RD ST W BLDG 1040
UNIVERSAL CITY TX
78150-4800
US

IV. Provider business mailing address

613 WILDCAT RUN
CIBOLO TX
78108-3495
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-3505
  • Fax:
Mailing address:
  • Phone: 219-789-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180014935
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number390041014A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number93611
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: