Provider Demographics
NPI:1588690028
Name:WITTKOP, WAYNE ELMER (LCSW)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:ELMER
Last Name:WITTKOP
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 WILLOW AVE APT 154
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3356
Mailing Address - Country:US
Mailing Address - Phone:818-269-8309
Mailing Address - Fax:
Practice Address - Street 1:VA-CBOC GUAM
Practice Address - Street 2:US NAVAL HOSPITAL
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GUAM USA
Practice Address - Zip Code:96919
Practice Address - Country:UM
Practice Address - Phone:671-344-9478
Practice Address - Fax:671-472-7249
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 7731104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker