Basic Information
Provider Information | |||||||||
NPI: | 1689977084 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEWIS | ||||||||
FirstName: | CHARLA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6315 GULFTON ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770811107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134574372 | ||||||||
FaxNumber: | 4692949175 | ||||||||
Practice Location | |||||||||
Address1: | 3025 E RENNER RD STE 303 | ||||||||
Address2: |   | ||||||||
City: | RICHARDSON | ||||||||
State: | TX | ||||||||
PostalCode: | 750823580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134574372 | ||||||||
FaxNumber: | 7134570945 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2010 | ||||||||
LastUpdateDate: | 06/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 04586 | MD | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | 1000544 | DC | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | 38413 | TX | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 037904200 | 05 | MD |   | MEDICAID | 1A6905 | 01 |   | MEDICARE | OTHER | 408966601 | 05 | TX |   | MEDICAID |