Provider Demographics
NPI:1699475392
Name:LEWIS, MARA MARTIN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:MARTIN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 CHESSA LN
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-5134
Mailing Address - Country:US
Mailing Address - Phone:559-816-3960
Mailing Address - Fax:
Practice Address - Street 1:3908 CHESSA LN
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-5134
Practice Address - Country:US
Practice Address - Phone:559-549-4806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37517235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist