Provider Demographics
NPI:1295262913
Name:OWENS, DEVOUGHN T
Entity type:Individual
Prefix:
First Name:DEVOUGHN
Middle Name:T
Last Name:OWENS
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 1:23580 MEADOWLARK ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2275
Mailing Address - Country:US
Mailing Address - Phone:248-545-0133
Mailing Address - Fax:248-864-8724
Practice Address - Street 1:23580 MEADOWLARK ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2275
Practice Address - Country:US
Practice Address - Phone:248-545-0133
Practice Address - Fax:248-864-8724
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704188778163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAS630247107OtherADULT FOSTER CARE PROVIDER FOR THE MENTALLY ILL AND DEVELOPMENTALLY DISABLED