=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366253866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPHEN DEWIT THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2025
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1428 44TH ST SW STE B
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49509-4312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-745-9391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1436 DERBYSHIRE ST SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508-2544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-745-9391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHEN ALBERT BERNARD DEWIT
-----------------------------------------------------
Credential | LLMSW
-----------------------------------------------------
Telephone | 616-745-9391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------