Basic Information
| Provider Information | |||||||||
| NPI: | 1740285774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012792010 | ||||||||
| FaxNumber: | 7012795649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 00416 | IA | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0140111 | 05 | IA | MEDICAID | 54513 | 01 | IA | BLUE CROSS OF IOWA | OTHER |