Provider Demographics
NPI:1568985836
Name:DEWITT, LACIE K (RBT)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:K
Last Name:DEWITT
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W LUDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:FARWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48622-9742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 W. LUDINGTON DR.
Practice Address - Street 2:
Practice Address - City:FARWELL
Practice Address - State:MI
Practice Address - Zip Code:48622
Practice Address - Country:US
Practice Address - Phone:989-429-1948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician