Provider Demographics
NPI:1396555611
Name:LEWIS, WILLIE
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12853 COCOA PINE DR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-6144
Mailing Address - Country:US
Mailing Address - Phone:561-614-9868
Mailing Address - Fax:
Practice Address - Street 1:12853 COCOA PINE DR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-6144
Practice Address - Country:US
Practice Address - Phone:561-614-9868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225142251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics