Provider Demographics
NPI:1073356598
Name:DE WIT, LISELOTTE (PHD)
Entity type:Individual
Prefix:
First Name:LISELOTTE
Middle Name:
Last Name:DE WIT
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 ARLINGTON PKWY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4506
Mailing Address - Country:US
Mailing Address - Phone:786-338-0735
Mailing Address - Fax:
Practice Address - Street 1:1441 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1004
Practice Address - Country:US
Practice Address - Phone:404-712-5667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004717103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist