Provider Demographics
NPI:1104600626
Name:WITZKE, DEREK (LLMSW)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:WITZKE
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5190 E 32 RD
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-9006
Mailing Address - Country:US
Mailing Address - Phone:231-878-7523
Mailing Address - Fax:
Practice Address - Street 1:805 S CARMEL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2344
Practice Address - Country:US
Practice Address - Phone:231-775-6517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511172011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical