Healthcare Provider Details

I. General information

NPI: 1316289739
Provider Name (Legal Business Name): GWENDOLINE C DEWITT PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2013
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date: 09/17/2025
Reactivation Date: 11/17/2025

III. Provider practice location address

302 S SENATOR RD
CRYSTAL MI
48818-9651
US

IV. Provider business mailing address

3943 W MAIN RD
STANTON MI
48888-9156
US

V. Phone/Fax

Practice location:
  • Phone: 989-831-9111
  • Fax:
Mailing address:
  • Phone: 907-317-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301018808
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: