Provider Demographics
NPI:1366191215
Name:LEWIS, AVERY LYNN (LLPC)
Entity type:Individual
Prefix:MS
First Name:AVERY
Middle Name:LYNN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24808 EAST RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138
Mailing Address - Country:US
Mailing Address - Phone:734-642-8892
Mailing Address - Fax:
Practice Address - Street 1:1 HERITAGE DR STE 261
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2574
Practice Address - Country:US
Practice Address - Phone:734-778-0663
Practice Address - Fax:734-785-8328
Is Sole Proprietor?:No
Enumeration Date:2022-03-19
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451019325101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health