=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770183956
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS LEWAN LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2020
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6549 TOWN CENTER DR STE A
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-395-3223
-----------------------------------------------------
Fax | 833-329-6632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6549 TOWN CENTER DR STE A
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-395-3223
-----------------------------------------------------
Fax | 833-329-6632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401223053
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401018742
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------