Provider Demographics
NPI:1477678829
Name:PITTAWAY, KATHLEEN CAMPBELL (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CAMPBELL
Last Name:PITTAWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 OLD WEST SHORE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH HERO
Mailing Address - State:VT
Mailing Address - Zip Code:05474-9616
Mailing Address - Country:US
Mailing Address - Phone:802-388-4822
Mailing Address - Fax:
Practice Address - Street 1:66 DICKERSON RD
Practice Address - Street 2:UPPER VALLEY SERVICES
Practice Address - City:MORETOWN
Practice Address - State:VT
Practice Address - Zip Code:05660-9103
Practice Address - Country:US
Practice Address - Phone:802-496-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00081882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0462Medicaid
VT0VN0462Medicaid