Healthcare Provider Details

I. General information

NPI: 1144380866
Provider Name (Legal Business Name): TAWA M WITKO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 6TH ST MCLAUGHLIN CLINIC
MCLAUGHLIN SD
57642
US

IV. Provider business mailing address

PO BOX 879 MCLAUGHLIN CLINIC
MC LAUGHLIN SD
57642-0879
US

V. Phone/Fax

Practice location:
  • Phone: 605-823-4458
  • Fax: 605-823-4459
Mailing address:
  • Phone: 605-823-4458
  • Fax: 605-823-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number456
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: