Provider Demographics
NPI:1780050708
Name:LEWIS, CARLYN ELLICIA
Entity type:Individual
Prefix:
First Name:CARLYN
Middle Name:ELLICIA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLYN
Other - Middle Name:J
Other - Last Name:DILLWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19853 OUTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2044
Mailing Address - Country:US
Mailing Address - Phone:248-508-3481
Mailing Address - Fax:
Practice Address - Street 1:19853 OUTER DR STE 110
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2044
Practice Address - Country:US
Practice Address - Phone:248-508-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst