Provider Demographics
NPI:1316289739
Name:DEWITT, GWENDOLINE C (PHD)
Entity type:Individual
Prefix:DR
First Name:GWENDOLINE
Middle Name:C
Last Name:DEWITT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 WATERFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9630
Mailing Address - Country:US
Mailing Address - Phone:989-292-3572
Mailing Address - Fax:
Practice Address - Street 1:1505 WATERFORD PKWY
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-9630
Practice Address - Country:US
Practice Address - Phone:989-292-3572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-24
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018808103TC0700X, 103TC1900X
AK119519103TC1900X
NY021514103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical