MEDICARE: KELLIE MARIE PITTMAN BCABA

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	106E00000X	Assistant Behavior Analyst	0-17-7999	IN

General Provider Information

NPI Number	:	1750899472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE MARIE PITTMAN BCABA

Provider Business Mailing Address
First Line	:	3711 E SOUTHPORT RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-7874
Country	:	US
Telephone Number	:	317-796-6668
Fax Number	:	317-759-2557

Provider Business Practice Location Address
First Line	:	1800 W 900 S
Second Line	:
City	:	FLAT ROCK
State	:	IN
Zip	:	47234-9773
Country	:	US
Telephone Number	:	317-512-2101
Fax Number	:

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

Provider Enumeration Date	:	01/16/2018
Last Update Date	:	05/09/2022

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