Provider Demographics
NPI:1205155603
Name:VON WITZLEBEN, MARY (PHD, BCBA)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:VON WITZLEBEN
Suffix:
Gender:F
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 809 BOX 2198
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09626-9997
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BLDG 2127 #4 US NAVAL BASE
Practice Address - Street 2:VIA CONTRADA BOSCARIELLO
Practice Address - City:GRICIGNANO DI AVERSA
Practice Address - State:CAMPANIA
Practice Address - Zip Code:81031
Practice Address - Country:IT
Practice Address - Phone:081-811-5934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1095675103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst