Basic Information
| Provider Information | |||||||||
| NPI: | 1417241407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOATNER | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010A SHANNAHAN DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422231170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134614984 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 UFFELMAN DR STE F | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370432970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319207333 | ||||||||
| FaxNumber: | 9319207331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2011 | ||||||||
| LastUpdateDate: | 06/07/2011 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.