Provider Demographics
NPI:1730796962
Name:WITTKOPP, CARMEN LEIGH (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:LEIGH
Last Name:WITTKOPP
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13697 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-8533
Mailing Address - Country:US
Mailing Address - Phone:269-781-6030
Mailing Address - Fax:
Practice Address - Street 1:13697 15 MILE RD
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-8533
Practice Address - Country:US
Practice Address - Phone:269-781-6030
Practice Address - Fax:269-781-3859
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101007237235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist