Basic Information
| Provider Information | |||||||||
| NPI: | 1750572327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITT | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC, QMHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MERAS | ||||||||
| OtherFirstName: | MARTA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, QMHP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 484 JUEDES AVE N | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973035452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9717078074 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1675 WINTER ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973017152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035850351 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | C3572 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.