Provider Demographics
NPI:1164134474
Name:WITTMER, MAKAYLA DAWN
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:DAWN
Last Name:WITTMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAKAYLA
Other - Middle Name:DAWN
Other - Last Name:WAGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:9502 E 400 N
Mailing Address - Street 2:
Mailing Address - City:LOOGOOTEE
Mailing Address - State:IN
Mailing Address - Zip Code:47553-5439
Mailing Address - Country:US
Mailing Address - Phone:812-259-1002
Mailing Address - Fax:
Practice Address - Street 1:300 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-1708
Practice Address - Country:US
Practice Address - Phone:812-709-3286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007910A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist