Provider Demographics
NPI:1043314560
Name:PITA, JOHN MANUEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MANUEL
Last Name:PITA
Suffix:
Gender:M
Credentials:PHD
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 226464
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75222-6464
Mailing Address - Country:US
Mailing Address - Phone:972-765-2643
Mailing Address - Fax:214-698-4497
Practice Address - Street 1:900 HEDGCOXE RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75025-2554
Practice Address - Country:US
Practice Address - Phone:972-765-2643
Practice Address - Fax:214-698-4497
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24790103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752657482OtherEIN
TX81765PMedicare PIN