Provider Demographics
NPI:1720787781
Name:WITTENBERG, EVANS (AMFT, APCC, MA)
Entity Type:Individual
Prefix:
First Name:EVANS
Middle Name:
Last Name:WITTENBERG
Suffix:
Gender:M
Credentials:AMFT, APCC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3462 1/2 FLOYD TER
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1426
Mailing Address - Country:US
Mailing Address - Phone:713-503-6726
Mailing Address - Fax:
Practice Address - Street 1:4620A HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5408
Practice Address - Country:US
Practice Address - Phone:713-503-6726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132884106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist