Healthcare Provider Details

I. General information

NPI: 1104600626
Provider Name (Legal Business Name): DEREK WITZKE LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 S CARMEL ST
CADILLAC MI
49601-2344
US

IV. Provider business mailing address

5190 E 32 RD
CADILLAC MI
49601-9006
US

V. Phone/Fax

Practice location:
  • Phone: 231-775-6517
  • Fax:
Mailing address:
  • Phone: 231-878-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851117201
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: