Provider Demographics
NPI:1245969112
Name:WITT, GLEN ELMER (LICDC-CS)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:ELMER
Last Name:WITT
Suffix:
Gender:M
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 ROSEDALE ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-3242
Mailing Address - Country:US
Mailing Address - Phone:419-320-3845
Mailing Address - Fax:419-824-1754
Practice Address - Street 1:6629 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1098
Practice Address - Country:US
Practice Address - Phone:419-740-5709
Practice Address - Fax:419-740-7323
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH965768101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)