Provider Demographics
NPI:1154394856
Name:DEWIT, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DEWIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 PORTE DE LEAU CT
Mailing Address - Street 2:#207
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2390
Mailing Address - Country:US
Mailing Address - Phone:219-781-3531
Mailing Address - Fax:
Practice Address - Street 1:1650 45TH AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3962
Practice Address - Country:US
Practice Address - Phone:219-922-8188
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001173A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer