Provider Demographics
NPI:1063703502
Name:LEWIS, AMANDA GWEN (LMT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GWEN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 S. HARBOR CITY BOULEVARD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901
Mailing Address - Country:US
Mailing Address - Phone:321-674-9900
Mailing Address - Fax:
Practice Address - Street 1:1900 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4749
Practice Address - Country:US
Practice Address - Phone:321-674-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist