=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518329671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGICAL PROFESSIONAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2016
-----------------------------------------------------
Last Update Date | 03/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38800 GARFIELD RD STE 100
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48038-6619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-231-0306
-----------------------------------------------------
Fax | 586-231-0307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38800 GARFIELD RD STE 100
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48038-6619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-231-0306
-----------------------------------------------------
Fax | 586-231-0307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. CHERYL ANN LEWIS
-----------------------------------------------------
Credential | PHD. LLP
-----------------------------------------------------
Telephone | 586-231-0306
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6301011383
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------