Basic Information
| Provider Information | |||||||||
| NPI: | 1306906706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8615 RIDGELYS CHOICE DR STE 212 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105292151 | ||||||||
| FaxNumber: | 4105271342 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 WEST MORENO AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726200 | ||||||||
| FaxNumber: | 7195726299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 02/01/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 07153 | MD | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 1650 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | KL86 | 01 | MD | BCBS | OTHER |