Provider Demographics
NPI:1992376966
Name:LEWIS, KERRY BRYANT (MINISTRY)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:BRYANT
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MINISTRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 S ALVARADO ST APT 301
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-4313
Mailing Address - Country:US
Mailing Address - Phone:323-635-0173
Mailing Address - Fax:
Practice Address - Street 1:725 S ALVARADO ST APT 301
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4313
Practice Address - Country:US
Practice Address - Phone:323-635-0173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95444626G80154Medicaid