Provider Demographics
NPI:1487808622
Name:DEWITT, KENNAN M
Entity type:Individual
Prefix:MR
First Name:KENNAN
Middle Name:M
Last Name:DEWITT
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 1:5420 PARK LAKE RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-3839
Mailing Address - Country:US
Mailing Address - Phone:517-420-7362
Mailing Address - Fax:
Practice Address - Street 1:2109 HAMILTON RD STE 202
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1700
Practice Address - Country:US
Practice Address - Phone:517-420-7362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008885101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional