Provider Demographics
NPI:1417338534
Name:LEWIS, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
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 1:11554 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2644
Mailing Address - Country:US
Mailing Address - Phone:586-558-0185
Mailing Address - Fax:586-558-7128
Practice Address - Street 1:6905 ROCHESTER RD
Practice Address - Street 2:SUITE C
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1282
Practice Address - Country:US
Practice Address - Phone:248-828-1100
Practice Address - Fax:248-828-1101
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003951225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant