Healthcare Provider Details

I. General information

NPI: 1386023638
Provider Name (Legal Business Name): MALINDA LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19184 RUTHERFORD ST
DETROIT MI
48235-2345
US

IV. Provider business mailing address

1887 YOSEMITE BLVD 23
BIRMINGHAM MI
48009-6549
US

V. Phone/Fax

Practice location:
  • Phone: 313-492-8566
  • Fax:
Mailing address:
  • Phone: 313-492-8566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: