MEDICARE: DR. DEMIETRICE LYNETTE PITTMAN PHD

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	103TC0700X	Clinical Psychologist	49855	MS

General Provider Information

NPI Number	:	1669794038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEMIETRICE LYNETTE PITTMAN PHD

Provider Business Mailing Address
First Line	:	2503 DUNSTAN RD
Second Line	:
City	:	JBSA FT SAM HOUSTON
State	:	TX
Zip	:	78234-7532
Country	:	US
Telephone Number	:	210-347-2047
Fax Number	:

Provider Business Practice Location Address
First Line	:	2503 DUNSTAN RD
Second Line	:
City	:	JBSA FT SAM HOUSTON
State	:	TX
Zip	:	78234-7532
Country	:	US
Telephone Number	:	210-347-2047
Fax Number	:

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

Provider Enumeration Date	:	02/25/2010
Last Update Date	:	09/05/2024

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