Provider Demographics
NPI:1972554772
Name:PITTNER, MARK STEPHEN (PHD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEPHEN
Last Name:PITTNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 W CENTRAL AVE
Mailing Address - Street 2:F1
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1135
Mailing Address - Country:US
Mailing Address - Phone:419-842-0860
Mailing Address - Fax:419-842-0861
Practice Address - Street 1:6800 W CENTRAL AVE
Practice Address - Street 2:F1
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1135
Practice Address - Country:US
Practice Address - Phone:419-842-0860
Practice Address - Fax:419-842-0861
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3256103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPICP 10152Medicare ID - Type Unspecified