Healthcare Provider Details

I. General information

NPI: 1841864295
Provider Name (Legal Business Name): KATHLEEN PITTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MARY ALICE PARK RD STE 304
CUMMING GA
30040-2683
US

IV. Provider business mailing address

16085 SEGWICK DR
MILTON GA
30004-4432
US

V. Phone/Fax

Practice location:
  • Phone: 443-414-1843
  • Fax:
Mailing address:
  • Phone: 443-414-1843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: