Healthcare Provider Details

I. General information

NPI: 1194370908
Provider Name (Legal Business Name): MARY A PITT BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 S FLORIDA AVE
LAKELAND FL
33813-2531
US

IV. Provider business mailing address

5120 S FLORIDA AVE STE 302
LAKELAND FL
33813-2527
US

V. Phone/Fax

Practice location:
  • Phone: 813-416-8808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-60005
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: