Basic Information
| Provider Information | |||||||||
| NPI: | 1730652819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | FAY | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 RESEARCH WAY | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897067913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758886610 | ||||||||
| FaxNumber: | 7758884904 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 CIVIC CENTER DR STE 224 | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890306332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022145948 | ||||||||
| FaxNumber: | 7022149430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2019 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 8226-C | NV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1730652819 | 05 | NV | MEDICAID |