Basic Information
| Provider Information | |||||||||
| NPI: | 1245969112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITT | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | ELMER | ||||||||
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| Credential: | LICDC-CS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1044 ROSEDALE ST | ||||||||
| Address2: | |||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435373242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193203845 | ||||||||
| FaxNumber: | 4198241754 | ||||||||
| Practice Location | |||||||||
| Address1: | 6629 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197405709 | ||||||||
| FaxNumber: | 4197407323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 965768 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.