Provider Demographics
NPI:1538218110
Name:WAITE, DENNIS EDWIN (EDD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:EDWIN
Last Name:WAITE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-0339
Mailing Address - Country:US
Mailing Address - Phone:269-471-5422
Mailing Address - Fax:269-473-3261
Practice Address - Street 1:5761 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-9683
Practice Address - Country:US
Practice Address - Phone:269-471-5422
Practice Address - Fax:269-473-3261
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006392103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A1-4515OtherBLUE CROSS BLUE SHIELD
MI0A1-4515OtherBLUE CROSS BLUE SHIELD