Provider Demographics
NPI:1902272495
Name:LEWIS, RANDI
Entity Type:Individual
Prefix:
First Name:RANDI
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:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:ARKOMA
Mailing Address - State:OK
Mailing Address - Zip Code:74901-0349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BLOCKER
Practice Address - Street 2:
Practice Address - City:ARKOMA
Practice Address - State:OK
Practice Address - Zip Code:74901-0349
Practice Address - Country:US
Practice Address - Phone:918-875-3835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14052499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist