Provider Demographics
NPI:1952746141
Name:WITTMAN, DEREK J (LMHC-D (NY),LPC (PA))
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:J
Last Name:WITTMAN
Suffix:
Gender:M
Credentials:LMHC-D (NY),LPC (PA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 THEODOLITE DR
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9346
Mailing Address - Country:US
Mailing Address - Phone:315-743-8050
Mailing Address - Fax:
Practice Address - Street 1:3737 THEODOLITE DR
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-9346
Practice Address - Country:US
Practice Address - Phone:315-281-9488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008137101YM0800X
PAPC013511101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03008275Medicaid