Provider Demographics
NPI:1508486333
Name:WITTEN, EVELYN AVIVA
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:AVIVA
Last Name:WITTEN
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 1:18 DUNLEITH DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-1895
Mailing Address - Country:US
Mailing Address - Phone:314-494-7286
Mailing Address - Fax:
Practice Address - Street 1:130 S BEMISTON AVE STE 604
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-1913
Practice Address - Country:US
Practice Address - Phone:314-862-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000143572101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional