=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639442601
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYN K LEWIS MCD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2012
-----------------------------------------------------
Last Update Date | 02/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11942 NE GLISAN ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97220-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-252-3238
-----------------------------------------------------
Fax | 503-253-8654
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11942 NE GLISAN ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97220-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-252-3238
-----------------------------------------------------
Fax | 503-253-8654
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | 23590
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------