Provider Demographics
NPI:1861250995
Name:LEWIS, NICHOLAS D'ANDRE
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:D'ANDRE
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 1:14701 BARTRAM PARK BLVD UNIT 1309
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5298
Mailing Address - Country:US
Mailing Address - Phone:904-589-4111
Mailing Address - Fax:
Practice Address - Street 1:14701 BARTRAM PARK BLVD UNIT 1309
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5298
Practice Address - Country:US
Practice Address - Phone:904-589-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst