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NPI Code Detail

MEDICARE: DR. MARY VON WITZLEBEN PHD, BCBA

MEDICARE: DR. MARY VON WITZLEBEN PHD, BCBA
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
1103K00000XBehavior Analyst1095675FL
2103T00000XPsychologist

General Provider Information

NPI Number : 1205155603
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARY VON WITZLEBEN PHD, BCBA
Provider Business Mailing Address
First Line : 1250 HILLRISE CIR
Second Line :
City : LAS CRUCES
State : NM
Zip : 88011-4741
Country : US
Telephone Number : 575-288-1881
Fax Number : 575-288-1889
Provider Business Practice Location Address
First Line : 1250 HILLRISE CIR
Second Line :
City : LAS CRUCES
State : NM
Zip : 88011-4741
Country : US
Telephone Number : 575-288-1881
Fax Number : 575-288-1889
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/25/2010
Last Update Date : 06/12/2025

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