Provider Demographics
NPI:1912315441
Name:LEWIS, VANESSA LORRAINE (6401012459)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:LORRAINE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:6401012459
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16250 NORTHLAND DR
Mailing Address - Street 2:SOUTHFIELD
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5205
Mailing Address - Country:US
Mailing Address - Phone:313-528-1402
Mailing Address - Fax:313-447-2277
Practice Address - Street 1:16250 NORTHLAND DR
Practice Address - Street 2:SOUTHFIELD
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5205
Practice Address - Country:US
Practice Address - Phone:313-528-1402
Practice Address - Fax:313-447-2277
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012459101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12739692OtherMERIDIAN