Provider Demographics
NPI:1578159984
Name:PITTALA, MICHAEL ROBERT
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:PITTALA
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 1:16 ARD CT
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-5903
Mailing Address - Country:US
Mailing Address - Phone:203-589-0871
Mailing Address - Fax:
Practice Address - Street 1:16 ARD CT
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-5903
Practice Address - Country:US
Practice Address - Phone:203-589-0871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2491106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist