1457429466 NPI number — DR. MITCHELL THOMAS WITTENBERG PH.D., LP

Table of content: DR. MITCHELL THOMAS WITTENBERG PH.D., LP (NPI 1457429466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457429466 NPI number — DR. MITCHELL THOMAS WITTENBERG PH.D., LP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITTENBERG
Provider First Name:
MITCHELL
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., LP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457429466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
687 DECORAH LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOTA HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55120-1672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-454-0398
Provider Business Mailing Address Fax Number:
651-698-0162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
JEWISH FAMILY SERVICE OF ST. PAUL
Provider Second Line Business Practice Location Address:
1633 WEST SEVENTH STREET
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-698-0767
Provider Business Practice Location Address Fax Number:
651-698-0162
Provider Enumeration Date:
11/30/2006

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: 103TC0700X , with the licence number:  LP3061 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 61-13693 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 112501 . This is a "HEALTHEAST CARE SYSTEM" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 7H396WI . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 104535 . This is a "UCARE OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 20124 . This is a "BEHAVIORAL HEALTHCARE PRO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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