Provider Demographics
NPI:1851980767
Name:WITZLING, LEIGH (R-DMT)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:WITZLING
Suffix:
Gender:F
Credentials:R-DMT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:LEIGH
Other - Last Name:WITZLING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:R-DMT
Mailing Address - Street 1:258 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MA
Mailing Address - Zip Code:01351-9515
Mailing Address - Country:US
Mailing Address - Phone:314-435-5682
Mailing Address - Fax:
Practice Address - Street 1:258 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MA
Practice Address - Zip Code:01351-9515
Practice Address - Country:US
Practice Address - Phone:314-435-5682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225600000X
VT097.0134440101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist