Provider Demographics
NPI:1356038061
Name:WITZIG, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WITZIG
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 1:132 MANLYN DR
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-2834
Mailing Address - Country:US
Mailing Address - Phone:314-971-4228
Mailing Address - Fax:
Practice Address - Street 1:2821 N BALLAS RD STE C37
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2313
Practice Address - Country:US
Practice Address - Phone:314-626-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220319911041C0700X
IN33011275A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical