Provider Demographics
NPI:1902011281
Name:WITTUM, MARI JO (MCP LCPC)
Entity Type:Individual
Prefix:MRS
First Name:MARI
Middle Name:JO
Last Name:WITTUM
Suffix:
Gender:F
Credentials:MCP LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-3705
Mailing Address - Country:US
Mailing Address - Phone:630-377-7171
Mailing Address - Fax:
Practice Address - Street 1:528 S BATAVIA AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2921
Practice Address - Country:US
Practice Address - Phone:630-482-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health