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General NPI Number Information
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NPI Number | 1598091928
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Entity Type | Individual
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Provider Name | JOEL DE WITT LPC
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Gender | Male
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Dates
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Enumeration Date | 10/20/2009
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Last Update Date | 05/28/2020
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Provider Practice Location Address
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Address Line | 4225 101ST ST UNIT 580302
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City | PLEASANT PRAIRIE
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State | WI
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Zip | 53158-6813
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Country | US
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Telephone | 262-320-7740
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Fax |
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Provider Business Mailing Address
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Address Line | 4225 101ST ST # 580302
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City | PLEASANT PRAIRIE
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State | WI
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Zip | 53158-9997
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Country | US
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Telephone | 262-320-7740
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 15673-132
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | C501198
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4756-125
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License Number State | WI
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