Provider Demographics
NPI:1669688081
Name:PITKETHLY, JOHN KELLY JR (CBHT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KELLY
Last Name:PITKETHLY
Suffix:JR
Gender:M
Credentials:CBHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4258 CLOVERLEAF PL
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-4703
Mailing Address - Country:US
Mailing Address - Phone:407-696-7102
Mailing Address - Fax:
Practice Address - Street 1:919 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-2101
Practice Address - Country:US
Practice Address - Phone:407-323-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health