Provider Demographics
NPI:1689966442
Name:LEWIS, CECIL JR (PASTOR)
Entity type:Individual
Prefix:
First Name:CECIL
Middle Name:
Last Name:LEWIS
Suffix:JR
Gender:M
Credentials:PASTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:THOREAU
Mailing Address - State:NM
Mailing Address - Zip Code:87323-1289
Mailing Address - Country:US
Mailing Address - Phone:505-905-0061
Mailing Address - Fax:505-905-0064
Practice Address - Street 1:.5 MILES EAST OF HWY 371
Practice Address - Street 2:.5 MILES EAST OF HWY 371
Practice Address - City:THOREAU
Practice Address - State:NM
Practice Address - Zip Code:87323-1289
Practice Address - Country:US
Practice Address - Phone:505-905-0061
Practice Address - Fax:505-905-0064
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM860092335OtherNAVAJO NATION