MEDICARE: HEATHER WITZKE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	65578	TX

General Provider Information

NPI Number	:	1720618572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER WITZKE LCSW

Provider Business Mailing Address
First Line	:	4521 SEVENTEEN LAKES CT
Second Line	:
City	:	ROANOKE
State	:	TX
Zip	:	76262-3741
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7524 MOSIER VIEW CT STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76118-7122
Country	:	US
Telephone Number	:	817-459-2401
Fax Number	:	817-549-5383

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2020
Last Update Date	:	01/21/2020

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