Provider Demographics
NPI:1457429466
Name:WITTENBERG, MITCHELL THOMAS (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:THOMAS
Last Name:WITTENBERG
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:687 DECORAH LN
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1672
Mailing Address - Country:US
Mailing Address - Phone:651-454-0398
Mailing Address - Fax:651-698-0162
Practice Address - Street 1:JEWISH FAMILY SERVICE OF ST. PAUL
Practice Address - Street 2:1633 WEST SEVENTH STREET
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-698-0767
Practice Address - Fax:651-698-0162
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP3061103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61-13693OtherUNITED BEHAVIORAL HEALTH
MN112501OtherHEALTHEAST CARE SYSTEM
MN7H396WIOtherBLUE CROSS BLUE SHIELD
MN104535OtherUCARE OF MN
MN20124OtherBEHAVIORAL HEALTHCARE PRO