=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780138834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CODY S. LEWIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2016
-----------------------------------------------------
Last Update Date | 08/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 602 S BUSEY AVE #1
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61801-4092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-605-8942
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 602 S BUSEY AVE #1
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61801-4092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-605-8942
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150.101685
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------