MEDICARE: MR. LEWIS REID MIKESELL LCSW

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	1041C0700X	Clinical Social Worker	0904000182	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	258045	OTHER	VA	ANTHEM PROVIDER NUMBER
2	A080974M	OTHER	VA	SENTARA HMO VETRI SYSTEMS

General Provider Information

NPI Number	:	1760433056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEWIS REID MIKESELL LCSW

Provider Business Mailing Address
First Line	:	2377 PRINCESS ANNE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-3535
Country	:	US
Telephone Number	:	757-427-5987
Fax Number	:	757-563-0887

Provider Business Practice Location Address
First Line	:	2377 PRINCESS ANNE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-3535
Country	:	US
Telephone Number	:	757-427-5987
Fax Number	:	757-563-0887

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	03/16/2011

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