=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184891996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGG ALLEN LEWIS PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2008
-----------------------------------------------------
Last Update Date | 11/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18826 N LOWER SACRAMENTO RD SUITE C
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95258-9290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-368-2532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18826 LOWER SACRAMENTO RD. SUITE C
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95258-9290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-368-2532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY15313
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------