Provider Demographics
NPI:1083378624
Name:WITTA, TREVOR XAVIER
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:XAVIER
Last Name:WITTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 N PROSPECT AVE APT 1006
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-2322
Mailing Address - Country:US
Mailing Address - Phone:317-403-9933
Mailing Address - Fax:
Practice Address - Street 1:790 N MILWAUKEE ST # 355
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3724
Practice Address - Country:US
Practice Address - Phone:317-403-9933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst