Provider Demographics
NPI:1407410525
Name:DEWALT, PATRICK T JR
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:T
Last Name:DEWALT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32100 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-2452
Mailing Address - Country:US
Mailing Address - Phone:248-712-4266
Mailing Address - Fax:
Practice Address - Street 1:1001 LAURENCE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2979
Practice Address - Country:US
Practice Address - Phone:517-740-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician