Provider Demographics
NPI:1053683219
Name:WITTWER, NICHOLAS J (MS, MFT)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:J
Last Name:WITTWER
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 MCKENNA BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-3922
Mailing Address - Country:US
Mailing Address - Phone:608-445-2364
Mailing Address - Fax:
Practice Address - Street 1:2722 MCKENNA BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-3922
Practice Address - Country:US
Practice Address - Phone:608-445-2364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI256-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist