Provider Demographics
NPI:1497257133
Name:PITTMAN, TYSHA KENYETTA (RMHCI)
Entity Type:Individual
Prefix:
First Name:TYSHA
Middle Name:KENYETTA
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 CASCADE CIR APT 208
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-8074
Mailing Address - Country:US
Mailing Address - Phone:321-947-6656
Mailing Address - Fax:
Practice Address - Street 1:1021 CASCADE CIR APT 208
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-8074
Practice Address - Country:US
Practice Address - Phone:321-947-6656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH16242101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty