Provider Demographics
NPI:1386023638
Name:LEWIS, MALINDA
Entity Type:Individual
Prefix:
First Name:MALINDA
Middle Name:
Last Name:LEWIS
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 1:1887 YOSEMITE BLVD
Mailing Address - Street 2:23
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6549
Mailing Address - Country:US
Mailing Address - Phone:313-492-8566
Mailing Address - Fax:
Practice Address - Street 1:19184 RUTHERFORD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2345
Practice Address - Country:US
Practice Address - Phone:313-492-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251S00000X, 253J00000X
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency