Provider Demographics
NPI:1205155603
Name:VON WITZLEBEN, MARY (PHD, BCBA)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:VON WITZLEBEN
Suffix:
Gender:F
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 HILLRISE CIR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4741
Mailing Address - Country:US
Mailing Address - Phone:575-288-1881
Mailing Address - Fax:575-288-1889
Practice Address - Street 1:1250 HILLRISE CIR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4741
Practice Address - Country:US
Practice Address - Phone:575-288-1881
Practice Address - Fax:575-288-1889
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1095675103K00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst