MEDICARE: EARL GORDON WITT MA

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	1885	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366427163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARL GORDON WITT MA

Provider Business Mailing Address
First Line	:	4300 S LOUISE AVE STE 201
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-3124
Country	:	US
Telephone Number	:	605-334-7713
Fax Number	:	605-334-5348

Provider Business Practice Location Address
First Line	:	4300 S LOUISE AVE STE 201
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-3124
Country	:	US
Telephone Number	:	605-334-7713
Fax Number	:	605-334-5348

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	05/06/2021

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Directions to “ EARL GORDON WITT MA” Practice Location

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