Provider Demographics
NPI:1124289301
Name:LEWIS, CARLA JOAN
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:JOAN
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:PO BOX 1153
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-4153
Mailing Address - Country:US
Mailing Address - Phone:606-598-0576
Mailing Address - Fax:
Practice Address - Street 1:307 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-1266
Practice Address - Country:US
Practice Address - Phone:606-598-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY949OtherKENTUCKY'S EARLY INTERVENTION SYSTEM FIRST STEPS