Provider Demographics
NPI:1679991046
Name:WITTE, CRISSE JORDAN (PSY)
Entity Type:Individual
Prefix:MS
First Name:CRISSE
Middle Name:JORDAN
Last Name:WITTE
Suffix:
Gender:F
Credentials:PSY
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:M
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1251 S GECKO RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-1223
Mailing Address - Country:US
Mailing Address - Phone:520-213-0411
Mailing Address - Fax:520-207-3801
Practice Address - Street 1:1251 S GECKO RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-1223
Practice Address - Country:US
Practice Address - Phone:520-213-0411
Practice Address - Fax:520-207-3801
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL19116350171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications