Provider Demographics
NPI:1396286357
Name:WITT, JOE (LP)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:WITT
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 ST. JOHN DRIVE
Mailing Address - Street 2:
Mailing Address - City:NETT LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55772
Mailing Address - Country:US
Mailing Address - Phone:218-757-3650
Mailing Address - Fax:
Practice Address - Street 1:5219 ST. JOHN DRIVE
Practice Address - Street 2:
Practice Address - City:NETT LAKE
Practice Address - State:MN
Practice Address - Zip Code:55772
Practice Address - Country:US
Practice Address - Phone:218-757-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP-0437103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLP-0437OtherSTATE