MEDICARE: IVES KENNETH WITTMAN LPCC

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	101YM0800X	Mental Health Counselor	CC02438	MN

General Provider Information

NPI Number	:	1356949432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVES KENNETH WITTMAN LPCC

Provider Business Mailing Address
First Line	:	767 HEINEL DR
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-2152
Country	:	US
Telephone Number	:	612-741-2152
Fax Number	:

Provider Business Practice Location Address
First Line	:	1828 JEFFERSON ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-4427
Country	:	US
Telephone Number	:	651-245-0417
Fax Number	:

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

Provider Enumeration Date	:	10/12/2020
Last Update Date	:	10/12/2020

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