Healthcare Provider Details

I. General information

NPI: 1083848451
Provider Name (Legal Business Name): PATRICIA M DEWITT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S NEWTON AVE
SPRINGFIELD MO
65806-2742
US

IV. Provider business mailing address

630 S NEWTON AVE
SPRINGFIELD MO
65806-2742
US

V. Phone/Fax

Practice location:
  • Phone: 417-865-6554
  • Fax:
Mailing address:
  • Phone: 417-865-6554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2003003711
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: