Healthcare Provider Details

I. General information

NPI: 1093626863
Provider Name (Legal Business Name): SHILOH MARIE SMITH-WITTWER LMHCA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4216 FLAGSTAFF CV
FORT WAYNE IN
46815-4417
US

IV. Provider business mailing address

4216 FLAGSTAFF CV
FORT WAYNE IN
46815-4417
US

V. Phone/Fax

Practice location:
  • Phone: 260-485-4357
  • Fax: 260-485-4357
Mailing address:
  • Phone: 260-485-4357
  • Fax: 260-485-4357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2406508
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number88002522A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: