Provider Demographics
NPI:1750572327
Name:WITT, MARTHA R (MS, LPC, QMHP)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:R
Last Name:WITT
Suffix:
Gender:F
Credentials:MS, LPC, QMHP
Other - Prefix:
Other - First Name:MARTA
Other - Middle Name:R
Other - Last Name:MERAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, QMHP
Mailing Address - Street 1:484 JUEDES AVE N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-5452
Mailing Address - Country:US
Mailing Address - Phone:971-707-8074
Mailing Address - Fax:
Practice Address - Street 1:1675 WINTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7152
Practice Address - Country:US
Practice Address - Phone:503-585-0351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
ORC3572101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator