Provider Demographics
NPI:1487004743
Name:WITTENBACH, NATHANIEL DAVID (DPT)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:DAVID
Last Name:WITTENBACH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3899 W FRONT ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8103
Mailing Address - Country:US
Mailing Address - Phone:231-421-9277
Mailing Address - Fax:
Practice Address - Street 1:3899 W FRONT ST
Practice Address - Street 2:UNIT 3
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8103
Practice Address - Country:US
Practice Address - Phone:231-421-9277
Practice Address - Fax:231-421-8447
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16613-24225100000X
MI5501017729225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist