Provider Demographics
NPI:1760506612
Name:WITTY, MARJORIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:
Last Name:WITTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 N KILBOURN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5912
Mailing Address - Country:US
Mailing Address - Phone:773-294-3514
Mailing Address - Fax:
Practice Address - Street 1:5604 N KILBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5912
Practice Address - Country:US
Practice Address - Phone:773-327-1046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004536103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical