Basic Information
| Provider Information | |||||||||
| NPI: | 1396086005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLBSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JESSOP | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1800 WEST BIG BEAVER ROAD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489185600 | ||||||||
| FaxNumber: | 2485303096 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 W BIG BEAVER RD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480843545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489185600 | ||||||||
| FaxNumber: | 2489185600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2013 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 6802087604 | MI | Y | Other Service Providers | Case Manager/Care Coordinator | 104100000X | 6802087604 | MI | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.