MEDICARE: DIAMOND YVETTE LEWIS

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

General Provider Information

NPI Number	:	1629508775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIAMOND YVETTE LEWIS

Provider Business Mailing Address
First Line	:	2600 ARROYO AVE APT 121
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-1857
Country	:	US
Telephone Number	:	832-888-8317
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 ARROYO AVE APT 121
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219
Country	:	US
Telephone Number	:	832-888-8317
Fax Number	:

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

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	07/21/2022

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