Provider Demographics
NPI:1609831304
Name:KITTLESON, CARL JAMES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:JAMES
Last Name:KITTLESON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:KITTLESON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:76 VETERANS AVE
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-0810
Mailing Address - Country:US
Mailing Address - Phone:607-664-4316
Mailing Address - Fax:607-664-4320
Practice Address - Street 1:76 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-0810
Practice Address - Country:US
Practice Address - Phone:607-664-4316
Practice Address - Fax:607-664-4320
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015593-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical