Provider Demographics
NPI:1497966154
Name:WITTE, MARY KAY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:WITTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 29TH LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-9649
Mailing Address - Country:US
Mailing Address - Phone:719-948-4609
Mailing Address - Fax:
Practice Address - Street 1:1471 29TH LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-9649
Practice Address - Country:US
Practice Address - Phone:719-948-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7169231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13783840Medicaid