Basic Information
Provider Information
NPI: 1225662018
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEWIS
FirstName: AMANDA
MiddleName: FAYE
NamePrefix: MS.
NameSuffix:  
Credential: LPC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6825 LAKE RD
Address2:  
City: PRINCE GEORGE
State: VA
PostalCode: 238754631
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 9407 CUMBERLAND RD
Address2:  
City: NEW KENT
State: VA
PostalCode: 231242029
CountryCode: US
TelephoneNumber: 8049662242
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/02/2020
LastUpdateDate: 03/02/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/02/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X0701008352VAY Behavioral Health & Social Service ProvidersCounselor 

No ID Information.


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