Provider Demographics
NPI:1174724694
Name:WITTENBERG, ALAN MARC (PT)
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:MARC
Last Name:WITTENBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 BALLARD DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1119
Mailing Address - Country:US
Mailing Address - Phone:860-233-6886
Mailing Address - Fax:860-233-6886
Practice Address - Street 1:69 BALLARD DR
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1119
Practice Address - Country:US
Practice Address - Phone:860-233-6886
Practice Address - Fax:860-233-6886
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002066225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist