Provider Demographics
NPI:1790021954
Name:PITTMAN, TRACY SHANA
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:SHANA
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-0839
Mailing Address - Country:US
Mailing Address - Phone:662-286-9883
Mailing Address - Fax:662-286-9836
Practice Address - Street 1:2441A COUNTY ROAD 501
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-9677
Practice Address - Country:US
Practice Address - Phone:662-837-8154
Practice Address - Fax:662-837-9462
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health