Provider Demographics
NPI:1295803609
Name:PITTS, TINA M (LCSW)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:M
Last Name:PITTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:PITTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:157 N CORONADO DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-6360
Mailing Address - Country:US
Mailing Address - Phone:520-308-1304
Mailing Address - Fax:
Practice Address - Street 1:157 N CORONADO DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6360
Practice Address - Country:US
Practice Address - Phone:520-308-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4066104100000X
NV3032-S104100000X
AZLCSW-130481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54523Medicaid