Provider Demographics
NPI:1275343733
Name:LEWIS, ELLICE
Entity type:Individual
Prefix:
First Name:ELLICE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 FRANCIS ST # 24071
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1772
Mailing Address - Country:US
Mailing Address - Phone:856-539-4790
Mailing Address - Fax:
Practice Address - Street 1:16 FRANCIS ST # 24071
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1772
Practice Address - Country:US
Practice Address - Phone:757-828-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX92598101Y00000X, 101YA0400X, 101YM0800X, 101YP1600X, 101YS0200X, 101YP2500X
171000000X, 171400000X, 374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No171000000XOther Service ProvidersMilitary Health Care Provider
No171400000XOther Service ProvidersHealth & Wellness Coach
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner