MEDICARE: KADIJA AMIRA LEWIS BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	4182	TX
3	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1104411610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KADIJA AMIRA LEWIS BCBA

Provider Business Mailing Address
First Line	:	5002 WISEMAN BLVD APT 9307
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-3803
Country	:	US
Telephone Number	:	210-710-3821
Fax Number	:

Provider Business Practice Location Address
First Line	:	419 CARSON HL STE 202
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-5500
Country	:	US
Telephone Number	:	210-634-1129
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2021
Last Update Date	:	10/14/2024

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