Provider Demographics
NPI:1396872479
Name:LEWIS, TED (LAC)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:MT
Mailing Address - Zip Code:59526-0219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 11TH ST W
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-4960
Practice Address - Country:US
Practice Address - Phone:406-262-9299
Practice Address - Fax:406-265-1071
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1099101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT760870OtherBLUE CHIP
MT760870OtherBLUECROSS BLUESHIELD