=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417309675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LISA LEWIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2016
-----------------------------------------------------
Last Update Date | 07/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6801 GRAY RD A1
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46237-3263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-512-1098
-----------------------------------------------------
Fax | 317-825-3050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6801 GRAY RD A1
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46237-3263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-512-1098
-----------------------------------------------------
Fax | 317-825-3050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | LISA MCCONNELL LEWIS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 317-512-1098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34004000A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------