MEDICARE: KELLIE MCDOUGALL LEWIS L.I.S.W-CP, CAC-AD

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	AC0396	MD
2	1041C0700X	Clinical Social Worker	10157	SC
3	1041C0700X	Clinical Social Worker	14474	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	SC1938C916	OTHER	SC	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C916	OTHER	SC	GROUP REAL COUNSELING LLC

General Provider Information

NPI Number	:	1265421937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE MCDOUGALL LEWIS L.I.S.W-CP, CAC-AD

Provider Business Mailing Address
First Line	:	PO BOX 31447
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-0025
Country	:	US
Telephone Number	:	843-273-0077
Fax Number	:	843-273-0075

Provider Business Practice Location Address
First Line	:	9403 HIGHWAY 707 STE B
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7758
Country	:	US
Telephone Number	:	843-273-0077
Fax Number	:	843-273-0075

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

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	01/31/2014

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Directions to “ KELLIE MCDOUGALL LEWIS L.I.S.W-CP, CAC-AD” Practice Location

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