Provider Demographics
NPI:1275040149
Name:WITMER, MACEY
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:
Last Name:WITMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SUNNYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66045-7599
Mailing Address - Country:US
Mailing Address - Phone:785-864-0771
Mailing Address - Fax:
Practice Address - Street 1:1000 SUNNYSIDE AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66045-7100
Practice Address - Country:US
Practice Address - Phone:785-864-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
KS18-60832106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator