=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053433037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENYATTA FATINA LEWIS LLMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13101 ALLEN RD ADULT OUTPATIENT MENTAL HEALTH, SUITE 100
-----------------------------------------------------
City | SOUTHGATE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48195-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-756-7705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41355 WILLIAMSBURG BLVD
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48187-3967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-895-1766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801088637
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------