=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467863548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONNIE LEWIS MSW, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2014
-----------------------------------------------------
Last Update Date | 02/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 JOEL DR
-----------------------------------------------------
City | FORT CAMPBELL
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42223-5318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-798-4097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2981 KANELL BLVD
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-712-2902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2013035565
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------