Provider Demographics
NPI:1194813949
Name:LEWIS, BRENDA JAMES (PHD)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:JAMES
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26677 W 12 MILE RD
Mailing Address - Street 2:SUITE #151
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1514
Mailing Address - Country:US
Mailing Address - Phone:313-920-2781
Mailing Address - Fax:248-352-8611
Practice Address - Street 1:26677 W 12 MILE RD
Practice Address - Street 2:SUITE #151
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1514
Practice Address - Country:US
Practice Address - Phone:313-920-2781
Practice Address - Fax:248-352-8611
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002406103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP36020001Medicare PIN