Provider Demographics
NPI:1205697356
Name:LEWIS, D'ANDRE
Entity type:Individual
Prefix:MR
First Name:D'ANDRE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1552
Mailing Address - Country:US
Mailing Address - Phone:209-468-8700
Mailing Address - Fax:
Practice Address - Street 1:1212 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1552
Practice Address - Country:US
Practice Address - Phone:209-468-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147531106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty