Provider Demographics
NPI:1629743398
Name:LEWIS, MICHELLE BRAGG (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BRAGG
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-3403
Mailing Address - Country:US
Mailing Address - Phone:424-442-0892
Mailing Address - Fax:
Practice Address - Street 1:1511 18TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3403
Practice Address - Country:US
Practice Address - Phone:310-722-0125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP10740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist