Healthcare Provider Details

I. General information

NPI: 1598977852
Provider Name (Legal Business Name): OLIVIA KRISTIN PITKETHLY LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 FERNWOOD BLVD
FERN PARK FL
32730-2116
US

IV. Provider business mailing address

4258 CLOVERLEAF PL
CASSELBERRY FL
32707-4703
US

V. Phone/Fax

Practice location:
  • Phone: 407-831-2411
  • Fax:
Mailing address:
  • Phone: 407-719-0704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: