Provider Demographics
NPI:1376285494
Name:BAWEJA, MARY JO (MA, LLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:BAWEJA
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:889 143RD AVE
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-9758
Mailing Address - Country:US
Mailing Address - Phone:616-821-1575
Mailing Address - Fax:
Practice Address - Street 1:889 143RD AVE
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-9758
Practice Address - Country:US
Practice Address - Phone:616-821-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361001393103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling