Provider Demographics
NPI:1790413250
Name:WITTE, EMMA ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:ELIZABETH
Last Name:WITTE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 PARK DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1636
Mailing Address - Country:US
Mailing Address - Phone:636-543-0628
Mailing Address - Fax:
Practice Address - Street 1:1120 W COMMERCE DR STE 100
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2392
Practice Address - Country:US
Practice Address - Phone:636-224-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019027414225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant