Provider Demographics
NPI:1497173553
Name:WITTE, BLAINE (LMFT)
Entity Type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:
Last Name:WITTE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:MR
Other - First Name:BLAINE
Other - Middle Name:KENT
Other - Last Name:WITTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:PO BOX 293945
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92329-3945
Mailing Address - Country:US
Mailing Address - Phone:760-985-9633
Mailing Address - Fax:
Practice Address - Street 1:15437 ANACAPA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2458
Practice Address - Country:US
Practice Address - Phone:760-985-9633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32868106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist