Provider Demographics
NPI:1568289270
Name:LITSCHAUER, THEODORE FULTON JR
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:FULTON
Last Name:LITSCHAUER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E MIRACLE STRIP PKWY STE 503
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 E MIRACLE STRIP PKWY STE 503
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1991
Practice Address - Country:US
Practice Address - Phone:252-529-9259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician