Provider Demographics
NPI:1144380866
Name:WITKO, TAWA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TAWA
Middle Name:M
Last Name:WITKO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 879
Mailing Address - Street 2:MCLAUGHLIN CLINIC
Mailing Address - City:MC LAUGHLIN
Mailing Address - State:SD
Mailing Address - Zip Code:57642-0879
Mailing Address - Country:US
Mailing Address - Phone:605-823-4458
Mailing Address - Fax:605-823-4459
Practice Address - Street 1:701 E 6TH ST
Practice Address - Street 2:MCLAUGHLIN CLINIC
Practice Address - City:MCLAUGHLIN
Practice Address - State:SD
Practice Address - Zip Code:57642
Practice Address - Country:US
Practice Address - Phone:605-823-4458
Practice Address - Fax:605-823-4459
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD456103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
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10025457300OtherNEBRASKA MEDICAID
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