MEDICARE: KELLY J PIZZITOLA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	34329	TX
2	103G00000X	Clinical Neuropsychologist	06-39P	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043410608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY J PIZZITOLA PH.D.

Provider Business Mailing Address
First Line	:	1 CHILDRENS WAY # 653
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-3500
Country	:	US
Telephone Number	:	501-364-1100
Fax Number	:	501-364-4082

Provider Business Practice Location Address
First Line	:	4610 W COMMERCIAL DR
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-7057
Country	:	US
Telephone Number	:	501-287-5229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	06/11/2024

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