Provider Demographics
NPI:1093863540
Name:DE WITT, DANIEL J (PSYD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:DE WITT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PARCHMENT DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3663
Mailing Address - Country:US
Mailing Address - Phone:616-957-9112
Mailing Address - Fax:616-957-2409
Practice Address - Street 1:1000 PARCHMENT DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3663
Practice Address - Country:US
Practice Address - Phone:616-957-9112
Practice Address - Fax:616-957-2409
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005950103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D145603682Medicare ID - Type Unspecified