MEDICARE: KELLY PITTMAN LCSW

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	1041C0700X	Clinical Social Worker	201700515	MO

General Provider Information

NPI Number	:	1538600507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY PITTMAN LCSW

Provider Business Mailing Address
First Line	:	2026 S BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2404
Country	:	US
Telephone Number	:	314-502-9460
Fax Number	:

Provider Business Practice Location Address
First Line	:	2026 S BIG BEND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2404
Country	:	US
Telephone Number	:	314-502-9460
Fax Number	:

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

Provider Enumeration Date	:	03/10/2017
Last Update Date	:	01/26/2023

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