Provider Demographics
NPI:1558412403
Name:DITMAR, LIJA VIJA (MSW)
Entity Type:Individual
Prefix:MS
First Name:LIJA
Middle Name:VIJA
Last Name:DITMAR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12719 S WEST BAY SHORE DR STE 7
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5489
Mailing Address - Country:US
Mailing Address - Phone:231-946-1610
Mailing Address - Fax:231-922-5046
Practice Address - Street 1:12719 S WEST BAY SHORE DR STE 7
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5489
Practice Address - Country:US
Practice Address - Phone:231-946-1610
Practice Address - Fax:231-922-5046
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010333901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical