Healthcare Provider Details

I. General information

NPI: 1174028237
Provider Name (Legal Business Name): CARISSA NOELLE WITTENBACH DPT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LEBANON RD STE D2
MINT HILL NC
28227-8265
US

IV. Provider business mailing address

580 EARLEY ST
KANNAPOLIS NC
28083-9207
US

V. Phone/Fax

Practice location:
  • Phone: 704-366-7723
  • Fax:
Mailing address:
  • Phone: 571-239-3610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP21321
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4668
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: