Basic Information
| Provider Information | |||||||||
| NPI: | 1043565419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | MELVILLE | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5275 CLAREMONT AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946181032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283885 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3301 E 12TH ST | ||||||||
| Address2: | SUITE 259 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304006574 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2012 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.