Provider Demographics
NPI:1164606570
Name:ERTZ, DEWEY J (EDD)
Entity Type:Individual
Prefix:DR
First Name:DEWEY
Middle Name:J
Last Name:ERTZ
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3900
Mailing Address - Country:US
Mailing Address - Phone:605-341-8647
Mailing Address - Fax:605-341-0489
Practice Address - Street 1:3601 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3900
Practice Address - Country:US
Practice Address - Phone:605-341-8647
Practice Address - Fax:605-341-0489
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD123101YA0400X, 103T00000X, 103TC0700X, 103TF0000X, 103TF0200X, 103TM1800X, 103TP2701X, 103TR0400X
SD29664-02103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6550193Medicaid
NE460461452-26Medicaid
NE460461452-26Medicaid