MEDICARE: LISA LAUREN WITTENBERG RDN, CDCES

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	133V00000X	Registered Dietitian	806083	MI

General Provider Information

NPI Number	:	1538803127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA LAUREN WITTENBERG RDN, CDCES

Provider Business Mailing Address
First Line	:	3631 BAYOU DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-1904
Country	:	US
Telephone Number	:	248-214-4396
Fax Number	:	248-353-1023

Provider Business Practice Location Address
First Line	:	3631 BAYOU DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48323-1904
Country	:	US
Telephone Number	:	248-214-4396
Fax Number	:	248-353-1023

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

Provider Enumeration Date	:	04/21/2022
Last Update Date	:	04/21/2022

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