Provider Demographics
NPI:1902516552
Name:LEWIS, ISIDORA IZZY
Entity Type:Individual
Prefix:
First Name:ISIDORA
Middle Name:IZZY
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 1:197 ROUTE 18 STE 3000
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-1440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:732-626-6298
Practice Address - Street 1:197 ROUTE 18 STE 3000
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-1440
Practice Address - Country:US
Practice Address - Phone:888-571-1521
Practice Address - Fax:732-626-6298
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YP2500X
171M00000X, 174400000X, 251C00000X
TXCERTIFICATE405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist
No405300000XOther Service ProvidersPrevention Professional