=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205221595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERRIE LEWIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2015
-----------------------------------------------------
Last Update Date | 04/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1221 W LAKEVIEW AVE
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32501-1836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-469-3500
-----------------------------------------------------
Fax | 850-595-1400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3686 US HIGHWAY 331 S
-----------------------------------------------------
City | DEFUNIAK SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32435-8463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-892-8045
-----------------------------------------------------
Fax | 850-892-8039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH13271
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------