Healthcare Provider Details

I. General information

NPI: 1235121385
Provider Name (Legal Business Name): JOHN THOMAS WITCHGER LMHP LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 FAYETTEVILLE ST
DURHAM NC
27707-2325
US

IV. Provider business mailing address

1301 FAYETTEVILLE ST
DURHAM NC
27707-2325
US

V. Phone/Fax

Practice location:
  • Phone: 919-956-4000
  • Fax:
Mailing address:
  • Phone: 919-956-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1968 LMHP
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number929 CMSW
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC009466
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: