Healthcare Provider Details

I. General information

NPI: 1760213169
Provider Name (Legal Business Name): ELISABETH DEWEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MONROE AVE NW
GRAND RAPIDS MI
49503-2211
US

IV. Provider business mailing address

PO BOX 752123
HOUSTON TX
77275-2123
US

V. Phone/Fax

Practice location:
  • Phone: 312-476-9064
  • Fax: 312-900-8230
Mailing address:
  • Phone: 312-746-9064
  • Fax: 312-900-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801117129
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: