Provider Demographics
NPI:1326318551
Name:WITTENBERG, LAURA L (MFT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:L
Last Name:WITTENBERG
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 MT DIABLO BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3618
Mailing Address - Country:US
Mailing Address - Phone:925-788-0901
Mailing Address - Fax:925-254-6798
Practice Address - Street 1:3704 MT DIABLO BLVD STE 203
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3618
Practice Address - Country:US
Practice Address - Phone:925-788-0901
Practice Address - Fax:925-254-6798
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 47508106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT475080OtherBLUE SHIELD OF CALIFORNIA