Provider Demographics
NPI:1689444655
Name:WITTIE, MADILYN JEWEL
Entity Type:Individual
Prefix:
First Name:MADILYN
Middle Name:JEWEL
Last Name:WITTIE
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 1:5405 AUBURN ST APT 1212
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-1684
Mailing Address - Country:US
Mailing Address - Phone:806-717-6173
Mailing Address - Fax:
Practice Address - Street 1:1614 AVENUE M STE 42
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-4952
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician