Provider Demographics
NPI:1679161640
Name:DETWILER, ISABEL NAOMI
Entity Type:Individual
Prefix:
First Name:ISABEL
Middle Name:NAOMI
Last Name:DETWILER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ISABEL
Other - Middle Name:NAOMI
Other - Last Name:THORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:58058 MARLENE DR
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-9346
Mailing Address - Country:US
Mailing Address - Phone:269-262-2400
Mailing Address - Fax:
Practice Address - Street 1:677 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-8524
Practice Address - Country:US
Practice Address - Phone:269-467-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802090857104100000X
MI6852090857104100000X
MI6851115926104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker