Provider Demographics
NPI:1376575787
Name:WITTE, ROXANNE RUTH (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:RUTH
Last Name:WITTE
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 1:222 N VERDE ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4636
Mailing Address - Country:US
Mailing Address - Phone:928-779-5118
Mailing Address - Fax:
Practice Address - Street 1:222 N VERDE ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4636
Practice Address - Country:US
Practice Address - Phone:928-779-5118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ1575103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0609640OtherBCBS PREFERRED PROVIDER
AZTHD1575BMedicare ID - Type UnspecifiedPSYCHOLOGIST