Healthcare Provider Details

I. General information

NPI: 1154882660
Provider Name (Legal Business Name): LUANN MARIE WITTROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 12/07/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N CIRCLE I RD
WILLCOX AZ
85643-3163
US

IV. Provider business mailing address

2901 N MANN DR
SILVER CITY NM
88061-5949
US

V. Phone/Fax

Practice location:
  • Phone: 520-384-2102
  • Fax:
Mailing address:
  • Phone: 575-654-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number000014
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: