Provider Demographics
NPI:1063277283
Name:DINNEWETH, MADDISON (CTRS)
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:
Last Name:DINNEWETH
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:MADDIE
Other - Middle Name:
Other - Last Name:DINNEWETH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CTRS
Mailing Address - Street 1:310 N FRONT
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-9307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-5102
Practice Address - Country:US
Practice Address - Phone:231-295-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI85004225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist