Provider Demographics
NPI:1033490172
Name:PITTARD, WILMA JENNIFER (NMT, CMT, LMT)
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:JENNIFER
Last Name:PITTARD
Suffix:
Gender:F
Credentials:NMT, CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 343
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30603-0343
Mailing Address - Country:US
Mailing Address - Phone:706-296-8000
Mailing Address - Fax:
Practice Address - Street 1:126 S MILLEDGE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-5666
Practice Address - Country:US
Practice Address - Phone:706-296-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT003330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT003330OtherGEORGIA STATE MASSAGE LICENSURE NUMBER