Provider Demographics
NPI:1992463418
Name:WITTE, TUPELO KEILLY (MA)
Entity type:Individual
Prefix:
First Name:TUPELO
Middle Name:KEILLY
Last Name:WITTE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15191 SW ROYALTY PKWY APT K12
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3960
Mailing Address - Country:US
Mailing Address - Phone:817-707-1511
Mailing Address - Fax:
Practice Address - Street 1:414 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2697
Practice Address - Country:US
Practice Address - Phone:817-707-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health