Provider Demographics
NPI:1508136045
Name:LEWIS, MICHELLE C (ATC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:LEWIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 WASHINGTON ST
Mailing Address - Street 2:#53
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-4302
Mailing Address - Country:US
Mailing Address - Phone:781-799-2254
Mailing Address - Fax:
Practice Address - Street 1:285 BABCOCK ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1003
Practice Address - Country:US
Practice Address - Phone:617-353-2746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer