=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154016277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL C DEWITT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2023
-----------------------------------------------------
Last Update Date | 04/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15320 S WILTON PL
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90249-4247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-409-4948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 MONTANA AVE APT 106
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-479-0256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 101844
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------