Healthcare Provider Details

I. General information

NPI: 1790195857
Provider Name (Legal Business Name): JAMES DEWEY LBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 CAMPUS DR N
WATERFORD MI
48328-2754
US

IV. Provider business mailing address

118 1/2 WOODFORD ST
MISSOULA MT
59801-4049
US

V. Phone/Fax

Practice location:
  • Phone: 248-633-5713
  • Fax:
Mailing address:
  • Phone: 248-633-5713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401000985
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: