Provider Demographics
NPI:1215341433
Name:DEWYSE, ELIZABETH IRENE (OTR/L)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:IRENE
Last Name:DEWYSE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 E KITCHEN RD
Mailing Address - Street 2:
Mailing Address - City:PINCONNING
Mailing Address - State:MI
Mailing Address - Zip Code:48650-7486
Mailing Address - Country:US
Mailing Address - Phone:989-879-4867
Mailing Address - Fax:
Practice Address - Street 1:694 E KITCHEN RD
Practice Address - Street 2:
Practice Address - City:PINCONNING
Practice Address - State:MI
Practice Address - Zip Code:48650-7486
Practice Address - Country:US
Practice Address - Phone:989-879-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3549529171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor