Provider Demographics
NPI:1124481866
Name:LEWIS, WANDA LOUISE
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:LOUISE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8623 W. WAYNE RD. HEGIRA PROGRAMS
Mailing Address - Street 2:SUITE 123
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8623 W. WAYNE RD.
Practice Address - Street 2:SUITE 123
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185
Practice Address - Country:US
Practice Address - Phone:734-367-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401004430101YP2500X
MI101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool