Provider Demographics
NPI:1891434825
Name:WITTER, CHARMAINE VIVIENNE
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:VIVIENNE
Last Name:WITTER
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 1:1200 E 53RD ST APT 6D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2342
Mailing Address - Country:US
Mailing Address - Phone:718-909-9043
Mailing Address - Fax:
Practice Address - Street 1:1200 E 53RD ST APT 6D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2342
Practice Address - Country:US
Practice Address - Phone:718-909-9043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-28
Last Update Date:2022-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1607685221106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY310778456OtherEMBLEM HEALTH