Provider Demographics
NPI:1750063749
Name:WITTKOP, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:WITTKOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 PRIGMORE ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 STULTS RD STE 137
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:NJ
Practice Address - Zip Code:08810-1549
Practice Address - Country:US
Practice Address - Phone:732-908-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)