Provider Demographics
NPI:1255302295
Name:PITKIN, GARY L
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:PITKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 FORT HILL RD
Mailing Address - Street 2:
Mailing Address - City:PUTNEY
Mailing Address - State:VT
Mailing Address - Zip Code:05346-8748
Mailing Address - Country:US
Mailing Address - Phone:802-387-4281
Mailing Address - Fax:
Practice Address - Street 1:190 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-2837
Practice Address - Country:US
Practice Address - Phone:802-254-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006833Medicaid
VT45680OtherMEGALLEN BEHAVIOR HEALTH
VT61227OtherMVP
NH30420993Medicaid
VT080-1606OtherBLUE CROSS/BLUE SHIELD