Provider Demographics
NPI:1063516268
Name:WICHTNER, RITA
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:WICHTNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51360 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-4219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 STODDARD RD.
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MI
Practice Address - Zip Code:41038-1038
Practice Address - Country:US
Practice Address - Phone:810-392-2167
Practice Address - Fax:810-392-2057
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)