Provider Demographics
NPI:1467477158
Name:WITTENBORN, PATRICIA M (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:M
Last Name:WITTENBORN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3941 WEATHERBY LN
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-0878
Mailing Address - Country:US
Mailing Address - Phone:229-333-2354
Mailing Address - Fax:
Practice Address - Street 1:2935 N ASHLEY ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1777
Practice Address - Country:US
Practice Address - Phone:229-247-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17917101YP2500X
GACSW0053261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional