Provider Demographics
NPI:1316509359
Name:THURSTON, LEWIS REID (BA)
Entity type:Individual
Prefix:
First Name:LEWIS
Middle Name:REID
Last Name:THURSTON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10709 NE FOX FARM RD
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OR
Mailing Address - Zip Code:97115-9119
Mailing Address - Country:US
Mailing Address - Phone:503-537-1166
Mailing Address - Fax:
Practice Address - Street 1:780 COMMERCIAL ST SE STE 104
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3465
Practice Address - Country:US
Practice Address - Phone:971-901-2731
Practice Address - Fax:971-901-3065
Is Sole Proprietor?:No
Enumeration Date:2019-06-29
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106S00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician