MEDICARE: TYLER WITZIG

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	1041C0700X	Clinical Social Worker	2022031991	MO

General Provider Information

NPI Number	:	1356038061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER WITZIG

Provider Business Mailing Address
First Line	:	132 MANLYN DR
Second Line	:
City	:	KIRKWOOD
State	:	MO
Zip	:	63122-2834
Country	:	US
Telephone Number	:	314-971-4228
Fax Number	:

Provider Business Practice Location Address
First Line	:	2821 N BALLAS RD STE C37
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2313
Country	:	US
Telephone Number	:	314-626-3226
Fax Number	:

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

Provider Enumeration Date	:	04/21/2023
Last Update Date	:	11/14/2024

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