Provider Demographics
NPI:1427541960
Name:LEWIS, KATHLEEN (PHD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KAT
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FUNCTIONAL MEDICINE
Mailing Address - Street 1:298 GLORIETTA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-3253
Mailing Address - Country:US
Mailing Address - Phone:415-845-9245
Mailing Address - Fax:
Practice Address - Street 1:298 GLORIETTA BLVD
Practice Address - Street 2:
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-3253
Practice Address - Country:US
Practice Address - Phone:415-845-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-09
Last Update Date:2018-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No101Y00000XBehavioral Health & Social Service ProvidersCounselor