Provider Demographics
NPI:1790280931
Name:KITTLE, TAMARA L
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:KITTLE
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 1:302 LARK ST
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-1104
Mailing Address - Country:US
Mailing Address - Phone:518-813-0580
Mailing Address - Fax:
Practice Address - Street 1:36-38 SACANDAGA RD
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-1893
Practice Address - Country:US
Practice Address - Phone:518-370-4272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool