=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134597958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WITTHOUSE HOLDINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2015
-----------------------------------------------------
Last Update Date | 09/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 N TREMONT ST
-----------------------------------------------------
City | KEWANEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61443-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-531-2803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23951 TOWER RD
-----------------------------------------------------
City | KEWANEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61443-8907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-531-2803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SARAH WITT
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 815-531-2803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 166000912
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------