Basic Information
| Provider Information | |||||||||
| NPI: | 1790413250 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTE | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 PARK DR | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630281636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6365430628 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1120 W COMMERCE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630282392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362247511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2022 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2019027414 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.