Provider Demographics
NPI:1093004293
Name:WITT, MILDRED MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MILDRED
Middle Name:MARY
Last Name:WITT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CRANE MEADOW PL
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-6859
Mailing Address - Country:US
Mailing Address - Phone:919-402-0349
Mailing Address - Fax:
Practice Address - Street 1:104 CRANE MEADOW PL
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-6859
Practice Address - Country:US
Practice Address - Phone:919-317-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3959103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10521964OtherCAQH
NC10521964OtherCAQH