Provider Demographics
NPI:1568686715
Name:WITTE, THEODORE W (LICSW)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:W
Last Name:WITTE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1491 SHERBURNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2416
Mailing Address - Country:US
Mailing Address - Phone:651-254-4370
Mailing Address - Fax:651-251-2190
Practice Address - Street 1:1491 SHERBURNE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2416
Practice Address - Country:US
Practice Address - Phone:651-254-4370
Practice Address - Fax:651-251-2190
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN153411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical