Provider Demographics
NPI:1033400304
Name:DEWICK, HOLLY ANN
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:DEWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 2430B
Mailing Address - Street 2:
Mailing Address - City:BIRCH TREE
Mailing Address - State:MO
Mailing Address - Zip Code:65438-9222
Mailing Address - Country:US
Mailing Address - Phone:573-292-1222
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 2430B
Practice Address - Street 2:
Practice Address - City:BIRCH TREE
Practice Address - State:MO
Practice Address - Zip Code:65438-9222
Practice Address - Country:US
Practice Address - Phone:573-292-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities