Healthcare Provider Details

I. General information

NPI: 1558756064
Provider Name (Legal Business Name): MILA NICOLE DEWITT BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 S LIBERTY ST
WINSTON SALEM NC
27101-5260
US

IV. Provider business mailing address

PO BOX 749
BELMONT NC
28012-0749
US

V. Phone/Fax

Practice location:
  • Phone: 336-934-4058
  • Fax: 743-255-3010
Mailing address:
  • Phone: 704-869-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number4242
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: