Healthcare Provider Details

I. General information

NPI: 1235704792
Provider Name (Legal Business Name): DALE LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 R DALE WERTZ DR
BAD AXE MI
48413-1365
US

IV. Provider business mailing address

1375 R DALE WERTZ DR
BAD AXE MI
48413-1365
US

V. Phone/Fax

Practice location:
  • Phone: 989-269-9293
  • Fax: 989-269-7544
Mailing address:
  • Phone: 989-269-9293
  • Fax: 989-269-7544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801109884
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: