Provider Demographics
NPI:1306911300
Name:LEWIS, BRANT WALTER (PT)
Entity type:Individual
Prefix:MR
First Name:BRANT
Middle Name:WALTER
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14851 SE 82ND DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7624
Mailing Address - Country:US
Mailing Address - Phone:503-656-0139
Mailing Address - Fax:503-557-4871
Practice Address - Street 1:14851 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7624
Practice Address - Country:US
Practice Address - Phone:503-656-0139
Practice Address - Fax:503-557-4871
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR007646Medicaid
ORR013654Medicare UPIN