Provider Demographics
NPI:1154956936
Name:LEWIS, VICTORIA RUBY
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:RUBY
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 1:7500 SAN FELIPE ST STE 990
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1708
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:866-611-1558
Practice Address - Street 1:515 PALM COAST PKWY SW STE 6/7
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4739
Practice Address - Country:US
Practice Address - Phone:386-951-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician