Provider Demographics
NPI:1952052250
Name:DEWAR, MICHELLE (LLP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DEWAR
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N RIVER ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3800
Mailing Address - Country:US
Mailing Address - Phone:810-309-9355
Mailing Address - Fax:810-750-1152
Practice Address - Street 1:127 N RIVER ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3800
Practice Address - Country:US
Practice Address - Phone:810-309-9355
Practice Address - Fax:810-750-1152
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63614007314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6361007314OtherLICENSE