Provider Demographics
NPI:1114187259
Name:DEWITT, RICHARD B (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:B
Last Name:DEWITT
Suffix:
Gender:M
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 BLACK OAK DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-789-4255
Mailing Address - Fax:541-789-5820
Practice Address - Street 1:781 BLACK OAK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9502
Practice Address - Country:US
Practice Address - Phone:541-789-4255
Practice Address - Fax:541-789-5820
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10495235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist