Healthcare Provider Details

I. General information

NPI: 1255508214
Provider Name (Legal Business Name): MICHAEL WITT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 CEDAR ST
WORCESTER MA
01609-2134
US

IV. Provider business mailing address

687 HIGHLAND AVE
NEEDHAM MA
02494-2232
US

V. Phone/Fax

Practice location:
  • Phone: 508-652-5414
  • Fax: 508-433-1871
Mailing address:
  • Phone: 800-455-8726
  • Fax: 866-455-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4990
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: