Provider Demographics
NPI:1699545640
Name:LEWIS, HEATHER (PHD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LUZETTE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:426 N ORCHARD DR APT 6
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3137
Mailing Address - Country:US
Mailing Address - Phone:951-532-2115
Mailing Address - Fax:
Practice Address - Street 1:501 S CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1222
Practice Address - Country:US
Practice Address - Phone:801-581-8280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12205695-2504103T00000X
UT12205695-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst