Provider Demographics
NPI:1699920199
Name:LEWIS, JOVIAL
Entity type:Individual
Prefix:MS
First Name:JOVIAL
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 SKILLMAN AVE
Mailing Address - Street 2:APR 3R
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4121
Mailing Address - Country:US
Mailing Address - Phone:718-507-4401
Mailing Address - Fax:718-690-3723
Practice Address - Street 1:5301 SKILLMAN AVE
Practice Address - Street 2:APR 3R
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4121
Practice Address - Country:US
Practice Address - Phone:718-507-4401
Practice Address - Fax:718-690-3723
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0278042251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics