Provider Demographics
NPI:1407357130
Name:LEWALD, MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LEWALD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 BYRON ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1702
Mailing Address - Country:US
Mailing Address - Phone:505-793-7692
Mailing Address - Fax:
Practice Address - Street 1:1400 N DRAKE RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-1978
Practice Address - Country:US
Practice Address - Phone:505-793-7692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005426235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty