Healthcare Provider Details

I. General information

NPI: 1154036788
Provider Name (Legal Business Name): JOSHUA LEWALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARKLANE BLVD STE 200E
DEARBORN MI
48126-2400
US

IV. Provider business mailing address

1 PARKLANE BLVD STE 200E
DEARBORN MI
48126-2400
US

V. Phone/Fax

Practice location:
  • Phone: 313-846-2606
  • Fax:
Mailing address:
  • Phone: 313-846-2606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: