Active NPI
Mitchell Thomas Wittenberg, PH.D., LP
- Clinical Psychologist
- St. Paul, MN
National Provider Identifier
1457429466
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- LP3061
- Practice address
- Jewish Family Service of St. Paul
1633 West Seventh Street
St. Paul, MN 55102 - Phone
- (651) 698-0767
- Fax
- (651) 698-0162
- NPI assigned
- Nov 30, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | LP3061 | MN | Primary |
Addresses
Primary practice location
Jewish Family Service of St. Paul
1633 West Seventh Street
St. Paul, MN 55102
Mailing address
687 Decorah LN
Mendota Heights, MN 55120-1672
Phone (651) 454-0398
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 61-13693 | Other | MN | UNITED BEHAVIORAL HEALTH |
| 112501 | Other | MN | HEALTHEAST CARE SYSTEM |
| 7H396WI | Other | MN | BLUE CROSS BLUE SHIELD |
| 104535 | Other | MN | UCARE OF MN |
| 20124 | Other | MN | BEHAVIORAL HEALTHCARE PRO |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LP3061 | MN | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1164844800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1457429466",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "687 DECORAH LN",
"city": "MENDOTA HEIGHTS",
"state": "MN",
"postal_code": "551201672",
"telephone_number": "651-454-0398",
"fax_number": "651-698-0162"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "JEWISH FAMILY SERVICE OF ST. PAUL",
"address_2": "1633 WEST SEVENTH STREET",
"city": "ST. PAUL",
"state": "MN",
"postal_code": "55102",
"telephone_number": "651-698-0767",
"fax_number": "651-698-0162"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WITTENBERG",
"first_name": "MITCHELL",
"middle_name": "THOMAS",
"name_prefix": "Dr.",
"credential": "PH.D., LP",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-11-30",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MN",
"license": "LP3061",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITED BEHAVIORAL HEALTH",
"identifier": "61-13693",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "HEALTHEAST CARE SYSTEM",
"identifier": "112501",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "7H396WI",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UCARE OF MN",
"identifier": "104535",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BEHAVIORAL HEALTHCARE PRO",
"identifier": "20124",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in St. Paul, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.