Provider Demographics
NPI:1730800418
Name:LEWIS, ELYSSIA N (LCSW)
Entity type:Individual
Prefix:MS
First Name:ELYSSIA
Middle Name:N
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71028 JIMENEZ ST # 1
Mailing Address - Street 2:
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-1761
Mailing Address - Country:US
Mailing Address - Phone:336-708-7170
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTE FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-7654
Practice Address - Country:US
Practice Address - Phone:254-287-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0151801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical