Healthcare Provider Details

I. General information

NPI: 1669880381
Provider Name (Legal Business Name): ANNE K WITTEMAN LPCC, LMAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4675 40TH AVE S STE 115
FARGO ND
58104-4592
US

IV. Provider business mailing address

4675 40TH AVE S STE 115
FARGO ND
58104-4592
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-0906
  • Fax: 701-478-0909
Mailing address:
  • Phone: 701-478-0906
  • Fax: 701-478-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1738
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number943-4-1-18-390
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: