Provider Demographics
NPI:1306350616
Name:LEWIS, BROOKE MAUREEN (LMSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MAUREEN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:MAUREEN
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:139 W BACON ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13480-1133
Mailing Address - Country:US
Mailing Address - Phone:315-525-4891
Mailing Address - Fax:
Practice Address - Street 1:2606 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6003
Practice Address - Country:US
Practice Address - Phone:315-525-4891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102650-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty