Provider Demographics
NPI:1720127061
Name:WITTENBERG, PAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:WITTENBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7212 SEAWORTHY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-3038
Mailing Address - Country:US
Mailing Address - Phone:714-374-1289
Mailing Address - Fax:714-374-5191
Practice Address - Street 1:7212 SEAWORTHY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-3038
Practice Address - Country:US
Practice Address - Phone:714-374-1289
Practice Address - Fax:714-374-5191
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5726103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY057260OtherMEDI-CAL PROVIDER NUMBER
CAPSY5726Medicare ID - Type Unspecified