Provider Demographics
NPI:1275295370
Name:LEWELLEN, PRISCILLA MARTINEZ
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:MARTINEZ
Last Name:LEWELLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 GREY FOX CT
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8176
Mailing Address - Country:US
Mailing Address - Phone:810-869-0148
Mailing Address - Fax:
Practice Address - Street 1:10683 S SAGINAW ST STE B
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8127
Practice Address - Country:US
Practice Address - Phone:810-771-4074
Practice Address - Fax:810-866-4450
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68510985751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical