Provider Demographics
NPI:1225678576
Name:PITTS, CRYSTAL AMANDA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AMANDA
Last Name:PITTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 WIMBERLEY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-8399
Mailing Address - Country:US
Mailing Address - Phone:405-317-7646
Mailing Address - Fax:
Practice Address - Street 1:1211 MAGNOLIA COURT
Practice Address - Street 2:SUITE 101
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160
Practice Address - Country:US
Practice Address - Phone:405-317-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
OK10602101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program