Provider Demographics
NPI:1225249501
Name:LEWIS, MICHELLE DAWN
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DAWN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:DAWN
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7200 BANCROFT AVE
Mailing Address - Street 2:STE 125-A
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2403
Mailing Address - Country:US
Mailing Address - Phone:510-777-3821
Mailing Address - Fax:
Practice Address - Street 1:7200 BANCROFT AVE
Practice Address - Street 2:SUITE 125-A
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2403
Practice Address - Country:US
Practice Address - Phone:510-777-3821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 22347104100000X
CA626551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker