Provider Demographics
NPI:1669017539
Name:PITTMAN, JUSTIN MATTHEW (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:PITTMAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-736-2574
Mailing Address - Fax:208-600-6064
Practice Address - Street 1:1739 S JADE WAY STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5898
Practice Address - Country:US
Practice Address - Phone:208-207-5454
Practice Address - Fax:208-600-6064
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT6538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist