Provider Demographics
NPI:1417037334
Name:LEWIS, MICHELE (MED LCADC-S, ICGC-I)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MED LCADC-S, ICGC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 BARTLETT AVENUE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5412
Mailing Address - Country:US
Mailing Address - Phone:443-613-0506
Mailing Address - Fax:
Practice Address - Street 1:640 BARTLETT AVENUE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5412
Practice Address - Country:US
Practice Address - Phone:443-613-0506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1079101YA0400X
MDLCA2207101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLICENSE# 1079OtherCLINICAL ADDICTION SPEC.
MDLCA2207OtherLCADC
NC6111892Medicaid