1528347366 NPI number — DR. KIZZY DIANNA PITTRELL EDD, LCPC

Table of content: DR. KIZZY DIANNA PITTRELL EDD, LCPC (NPI 1528347366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528347366 NPI number — DR. KIZZY DIANNA PITTRELL EDD, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PITTRELL
Provider First Name:
KIZZY
Provider Middle Name:
DIANNA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
EDD, LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSS
Provider Other First Name:
KIZZY
Provider Other Middle Name:
DIANNA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
EDD, LCPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528347366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 MIDDLE RIVER ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLE RIVER
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-609-9887
Provider Business Mailing Address Fax Number:
301-609-7284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 MIDDLE RIVER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLE RIVER
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-868-7762
Provider Business Practice Location Address Fax Number:
443-868-7643
Provider Enumeration Date:
08/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 589561800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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