Provider Demographics
NPI:1942452347
Name:WITTEBORT, KEN N
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:N
Last Name:WITTEBORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:PGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237
Mailing Address - Country:US
Mailing Address - Phone:412-369-9955
Mailing Address - Fax:
Practice Address - Street 1:1105 PERRY HWY
Practice Address - Street 2:
Practice Address - City:PGH.
Practice Address - State:PA
Practice Address - Zip Code:15237
Practice Address - Country:US
Practice Address - Phone:412-369-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE005358L225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant