Provider Demographics
NPI:1922728229
Name:FEDEWA, MARIAH
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:FEDEWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-5474
Mailing Address - Country:US
Mailing Address - Phone:517-394-7867
Mailing Address - Fax:517-394-7869
Practice Address - Street 1:4902 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-5474
Practice Address - Country:US
Practice Address - Phone:517-394-7867
Practice Address - Fax:517-394-7869
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No156F00000XEye and Vision Services ProvidersTechnician/Technologist