1093550865 NPI number — SALLY KENTON WITMER LCSW

Table of content: MARY-ROSE STORY (NPI 1093386005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093550865 NPI number — SALLY KENTON WITMER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITMER
Provider First Name:
SALLY
Provider Middle Name:
KENTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WITMER
Provider Other First Name:
SALLY
Provider Other Middle Name:
ELIZABETH KENTON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093550865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8697 LA MESA BLVD STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA MESA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91942-9565
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-221-1378
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VMR THERAPY
Provider Second Line Business Practice Location Address:
5012 CENTRAL AVE, SUITE F
Provider Business Practice Location Address City Name:
BONITA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-636-0909
Provider Business Practice Location Address Fax Number:
619-500-5834
Provider Enumeration Date:
06/25/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  124660 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)