Basic Information
| Provider Information | |||||||||
| NPI: | 1891891586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEWEY | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 NEEDHAM ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024611615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 6176300141 | ||||||||
| Practice Location | |||||||||
| Address1: | 3720 N 124TH ST | ||||||||
| Address2: | SUITE F | ||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532222100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145358134 | ||||||||
| FaxNumber: | 4145358135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 455-156 | WI | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | P00145930 | 01 | WI | RAILROAD | OTHER | 41149100 | 05 | WI | MEDICAID |