Provider Demographics
NPI:1215005145
Name:DEWIT, BERNADETTE JOAN
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:JOAN
Last Name:DEWIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BERNIE
Other - Middle Name:
Other - Last Name:DORGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:150 FOAL DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-3511
Mailing Address - Country:US
Mailing Address - Phone:770-650-9696
Mailing Address - Fax:
Practice Address - Street 1:1 MCGARITY ROAD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115
Practice Address - Country:US
Practice Address - Phone:770-360-9183
Practice Address - Fax:770-360-8965
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT0001266225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA505898257CMedicaid
GA10035430OtherAMERIGROUP
GA505898257BOtherPEACH STATE HEALTH PLAN
GA308507OtherWELLCARE
GA505898257BMedicaid