Provider Demographics
NPI:1417583279
Name:LEWIS, MALLORY AMANDA (AMFT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:AMANDA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 W SHAW LN STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2777
Mailing Address - Country:US
Mailing Address - Phone:559-443-4800
Mailing Address - Fax:559-443-4800
Practice Address - Street 1:2560 W SHAW LN STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-2777
Practice Address - Country:US
Practice Address - Phone:559-443-4800
Practice Address - Fax:559-443-4800
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139645106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA118150OtherBBS REGISTRATION