Provider Demographics
NPI:1558305409
Name:HEWITT, MARIAH (PSYD)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:HEWITT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:
Other - Last Name:FELDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:409 KENNEDY CT W
Mailing Address - Street 2:
Mailing Address - City:COLGATE
Mailing Address - State:WI
Mailing Address - Zip Code:53017-9749
Mailing Address - Country:US
Mailing Address - Phone:262-993-4402
Mailing Address - Fax:
Practice Address - Street 1:840 LAKE AVE
Practice Address - Street 2:STE 101
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1566
Practice Address - Country:US
Practice Address - Phone:262-634-8688
Practice Address - Fax:262-634-7547
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2534-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40960500Medicaid