Provider Demographics
NPI:1407595580
Name:WITTRUP, ERIK MATTHEW (LMSW)
Entity Type:Individual
Prefix:MR
First Name:ERIK
Middle Name:MATTHEW
Last Name:WITTRUP
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1490
Mailing Address - Country:US
Mailing Address - Phone:269-248-7179
Mailing Address - Fax:
Practice Address - Street 1:800 E MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1490
Practice Address - Country:US
Practice Address - Phone:269-249-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68510960461041C0700X
MI68011170831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical