Healthcare Provider Details

I. General information

NPI: 1881509545
Provider Name (Legal Business Name): PATRICK ITTLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9401 ROBERTS DR APT 29Q
SANDY SPRINGS GA
30350-1536
US

IV. Provider business mailing address

9401 ROBERTS DR APT 29Q
SANDY SPRINGS GA
30350-1536
US

V. Phone/Fax

Practice location:
  • Phone: 802-355-4865
  • Fax:
Mailing address:
  • Phone: 802-355-4865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT002418
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: