Provider Demographics
NPI:1578770517
Name:LEWIS, NIKKETTA (MSW)
Entity Type:Individual
Prefix:
First Name:NIKKETTA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 EASTERN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4737
Mailing Address - Country:US
Mailing Address - Phone:616-776-0891
Mailing Address - Fax:616-233-0672
Practice Address - Street 1:200 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4735
Practice Address - Country:US
Practice Address - Phone:616-776-0891
Practice Address - Fax:616-233-0672
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801087777104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker