Provider Demographics
NPI:1225833130
Name:LEWIS, RAFAEL (LADC)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:LEWIS
Suffix:
Gender:
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 66TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1718
Mailing Address - Country:US
Mailing Address - Phone:612-203-6414
Mailing Address - Fax:
Practice Address - Street 1:2901 66TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-1718
Practice Address - Country:US
Practice Address - Phone:612-203-6414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-14
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306118101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)