Provider Demographics
NPI:1730149295
Name:DEWITT, MARY JANN (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANN
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 1:22 W 1800 S
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-5243
Mailing Address - Country:US
Mailing Address - Phone:801-296-8408
Mailing Address - Fax:
Practice Address - Street 1:1104 E ASHTON AVE STE 108
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2348
Practice Address - Country:US
Practice Address - Phone:801-510-4547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT308921-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD1487Medicaid