Provider Demographics
NPI:1598528390
Name:WITHEM, DEBORAH A (LMT)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:WITHEM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5980 MARINE PKWY APT H110
Mailing Address - Street 2:
Mailing Address - City:MENTOR ON THE LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8502
Mailing Address - Country:US
Mailing Address - Phone:216-258-6146
Mailing Address - Fax:
Practice Address - Street 1:57424 MEGAN DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48094-3816
Practice Address - Country:US
Practice Address - Phone:586-255-7471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501016128225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty