Healthcare Provider Details

I. General information

NPI: 1720634876
Provider Name (Legal Business Name): OLIVIA JOYCE DEWITTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 WOODLAWN RD
STERLING IL
61081-4151
US

IV. Provider business mailing address

513 W RIVERSIDE DR
PROPHETSTOWN IL
61277-1051
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-0013
  • Fax:
Mailing address:
  • Phone: 815-718-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: