Provider Demographics
NPI:1265109821
Name:PITTMAN, TERRENCE
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:PITTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 N PEACE HAVEN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4850
Mailing Address - Country:US
Mailing Address - Phone:336-560-7878
Mailing Address - Fax:
Practice Address - Street 1:145 W KINDERTON WAY
Practice Address - Street 2:APT 301
Practice Address - City:BERMUDA RUN
Practice Address - State:NC
Practice Address - Zip Code:27006
Practice Address - Country:US
Practice Address - Phone:336-560-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician