Provider Demographics
NPI:1861637589
Name:GITTELSON, MYAH TARNOW (PSYD)
Entity Type:Individual
Prefix:
First Name:MYAH
Middle Name:TARNOW
Last Name:GITTELSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E KINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4743
Mailing Address - Country:US
Mailing Address - Phone:704-376-0550
Mailing Address - Fax:
Practice Address - Street 1:6025 BLAKENEY PARK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-5703
Practice Address - Country:US
Practice Address - Phone:704-376-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102803 PROVISIONAL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist