Healthcare Provider Details

I. General information

NPI: 1548658263
Provider Name (Legal Business Name): LINCOLN TYLER WITT M.A., L.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 COUNTRY CLUB RD STE A100
EUGENE OR
97401-6004
US

IV. Provider business mailing address

895 COUNTRY CLUB RD STE A100
EUGENE OR
97401-6004
US

V. Phone/Fax

Practice location:
  • Phone: 503-740-1818
  • Fax: 855-476-6169
Mailing address:
  • Phone: 503-740-1818
  • Fax: 855-476-6169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4452
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC3843
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2167
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC3843
License Number StateOR

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: