Provider Demographics
NPI:1609678374
Name:DEWICK, CORBIN JON
Entity type:Individual
Prefix:
First Name:CORBIN
Middle Name:JON
Last Name:DEWICK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8704
Mailing Address - Country:US
Mailing Address - Phone:417-247-1809
Mailing Address - Fax:
Practice Address - Street 1:4396 W DELMAR ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-7809
Practice Address - Country:US
Practice Address - Phone:417-501-8213
Practice Address - Fax:417-501-8213
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities