Provider Demographics
NPI:1720634876
Name:DEWITTE, OLIVIA JOYCE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JOYCE
Last Name:DEWITTE
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 1:513 W RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PROPHETSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:61277-1051
Mailing Address - Country:US
Mailing Address - Phone:815-718-5331
Mailing Address - Fax:
Practice Address - Street 1:2611 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-4151
Practice Address - Country:US
Practice Address - Phone:815-625-0013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health