Healthcare Provider Details

I. General information

NPI: 1972898260
Provider Name (Legal Business Name): THEDA WITT HAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 MENAUL BLVD NE
ALBUQUERQUE NM
87107-1852
US

IV. Provider business mailing address

8800 SE SUNNYSIDE RD 300-N
CLACKAMAS OR
97015-5738
US

V. Phone/Fax

Practice location:
  • Phone: 505-889-9100
  • Fax: 505-888-0363
Mailing address:
  • Phone: 503-659-5115
  • Fax: 866-448-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number486
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: