Healthcare Provider Details

I. General information

NPI: 1689212862
Provider Name (Legal Business Name): LARA DEWITT M.ED, SCL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 CENTURY LN
HOLLAND MI
49423-4286
US

IV. Provider business mailing address

483 CENTURY LN
HOLLAND MI
49423-4286
US

V. Phone/Fax

Practice location:
  • Phone: 616-396-5284
  • Fax:
Mailing address:
  • Phone: 616-355-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberSC0000001012118
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: