Basic Information
| Provider Information | |||||||||
| NPI: | 1457710709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTWER | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 N BUFFALO DR UNIT 170 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891283637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025646712 | ||||||||
| FaxNumber: | 7025644838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 NEVADA WAY STE 205 | ||||||||
| Address2: | |||||||||
| City: | BOULDER CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890051829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022462782 | ||||||||
| FaxNumber: | 7027501372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 225X00000X | OT-2564 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.