MEDICARE: MICHELLE LEWIS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6198245-3501	UT

General Provider Information

NPI Number	:	1558676338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE LEWIS LCSW

Provider Business Mailing Address
First Line	:	7105 HIGHLAND DR
Second Line	:	STE 303
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3753
Country	:	US
Telephone Number	:	801-907-1391
Fax Number	:

Provider Business Practice Location Address
First Line	:	7105 S. HIGHLAND DR.
Second Line	:	STE 303
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:	801-907-1391
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2010
Last Update Date	:	08/17/2010

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