Provider Demographics
NPI:1093563371
Name:LEWIS, HAVEN
Entity type:Individual
Prefix:
First Name:HAVEN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4986 SE LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3843
Mailing Address - Country:US
Mailing Address - Phone:609-706-2761
Mailing Address - Fax:
Practice Address - Street 1:6400 SE LAKE RD STE 250
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2129
Practice Address - Country:US
Practice Address - Phone:541-900-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8987101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor