Provider Demographics
NPI:1558181131
Name:WITZKE, REBECCA
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:WITZKE
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:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34460-0007
Mailing Address - Country:US
Mailing Address - Phone:219-281-6090
Mailing Address - Fax:
Practice Address - Street 1:935 S CRYSTAL GLEN DR
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-8364
Practice Address - Country:US
Practice Address - Phone:219-281-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL182941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical