Provider Demographics
NPI:1891933016
Name:WITT, MICHELLE RAE (MF)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:WITT
Suffix:
Gender:F
Credentials:MF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14049 BOYS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SLOUGHHOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95683-9782
Mailing Address - Country:US
Mailing Address - Phone:916-294-0629
Mailing Address - Fax:
Practice Address - Street 1:14049 BOYS RANCH RD
Practice Address - Street 2:
Practice Address - City:SLOUGHHOUSE
Practice Address - State:CA
Practice Address - Zip Code:95683-9782
Practice Address - Country:US
Practice Address - Phone:916-294-0629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40932106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist