Provider Demographics
NPI:1902020944
Name:WITT, MICHELLE R (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:R
Last Name:WITT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 BURNS FARM BLVD N
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2498
Mailing Address - Country:US
Mailing Address - Phone:184-013-8256
Mailing Address - Fax:
Practice Address - Street 1:210 BURNS FARM BLVD N
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2498
Practice Address - Country:US
Practice Address - Phone:618-401-3825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0123611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-012361OtherLCSW