=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083205595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEYNDRA LEWIS LMFT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2021
-----------------------------------------------------
Last Update Date | 12/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49 BROAD ST
-----------------------------------------------------
City | PLAINVILLE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06062-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-329-0645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 157
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06444-0157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-329-0645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEYNDRA LEWIS
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 203-449-1123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------