Provider Demographics
NPI:1154926228
Name:LEWIS, NICOLE R
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:R
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 1:4530 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3207
Mailing Address - Country:US
Mailing Address - Phone:937-241-4641
Mailing Address - Fax:
Practice Address - Street 1:7016 CORPORATE WAY
Practice Address - Street 2:
Practice Address - City:WASHINGTON TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45459-4300
Practice Address - Country:US
Practice Address - Phone:937-951-2084
Practice Address - Fax:877-739-5359
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-22-219414106S00000X
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No376J00000XNursing Service Related ProvidersHomemaker