Basic Information
| Provider Information | |||||||||
| NPI: | 1134506819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | DONALD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925834121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514878883 | ||||||||
| FaxNumber: | 9514877949 | ||||||||
| Practice Location | |||||||||
| Address1: | 22659 LAGUNA DR | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925537882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184808936 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2015 | ||||||||
| LastUpdateDate: | 11/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 80267 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | 80267 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.