Healthcare Provider Details

I. General information

NPI: 1104114966
Provider Name (Legal Business Name): MICHELLE LEWIS MA, LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 W 7 MILE RD
DETROIT MI
48203-1967
US

IV. Provider business mailing address

19758 PATTON ST
DETROIT MI
48219-2052
US

V. Phone/Fax

Practice location:
  • Phone: 313-893-6172
  • Fax: 313-893-0064
Mailing address:
  • Phone: 313-244-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301010219
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: