Provider Demographics
NPI:1053740662
Name:LEWIS, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-1769
Mailing Address - Country:US
Mailing Address - Phone:931-723-3051
Mailing Address - Fax:931-723-3632
Practice Address - Street 1:604 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-1769
Practice Address - Country:US
Practice Address - Phone:931-723-3051
Practice Address - Fax:931-723-3632
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000013631251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health