Healthcare Provider Details

I. General information

NPI: 1649733213
Provider Name (Legal Business Name): ERIC R WITT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 14TH AVE
LONGVIEW WA
98632-3017
US

IV. Provider business mailing address

1116 14TH AVE
LONGVIEW WA
98632-3017
US

V. Phone/Fax

Practice location:
  • Phone: 360-669-3702
  • Fax:
Mailing address:
  • Phone: 360-669-3702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61416246
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: