=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679586747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. ANDREA MARIE DEWASME
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 01/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1526 CREEK DR
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-6862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-416-1132
-----------------------------------------------------
Fax | 815-416-1135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 E NORTH ST
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-2345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-416-1132
-----------------------------------------------------
Fax | 815-416-1135
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038-009326
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------