Provider Demographics
NPI:1306104005
Name:LEWIS, BRIAN L (PHD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-5238
Mailing Address - Country:US
Mailing Address - Phone:540-344-2217
Mailing Address - Fax:540-344-0182
Practice Address - Street 1:1317 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5238
Practice Address - Country:US
Practice Address - Phone:540-344-2217
Practice Address - Fax:540-344-0182
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004763103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth