MEDICARE: CARISSA NOELLE WITTENBACH DPT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	P21321	NC
2	2255A2300X	Athletic Trainer	LAT-4668	NC

General Provider Information

NPI Number	:	1174028237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARISSA NOELLE WITTENBACH DPT, ATC

Provider Business Mailing Address
First Line	:	580 EARLEY ST
Second Line	:
City	:	KANNAPOLIS
State	:	NC
Zip	:	28083-9207
Country	:	US
Telephone Number	:	571-239-3610
Fax Number	:

Provider Business Practice Location Address
First Line	:	4700 LEBANON RD STE D2
Second Line	:
City	:	MINT HILL
State	:	NC
Zip	:	28227-8265
Country	:	US
Telephone Number	:	704-366-7723
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	12/04/2025

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