Provider Demographics
NPI:1962419424
Name:WITTENBERG, LINDA (LCMHC)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:WITTENBERG
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 ADAMS CT
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4100
Mailing Address - Country:US
Mailing Address - Phone:802-864-3556
Mailing Address - Fax:
Practice Address - Street 1:2 CHURCH ST.
Practice Address - Street 2:SUITE 2 D
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-658-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000340101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT068 0000340OtherVERMONT LICENSE NUMBER
VT29516OtherBLUE CROSS BLUE SHIELD
VT1006778Medicaid