Provider Demographics
NPI:1720631005
Name:KITTERMAN, ELYSE JILL (LPC, CSAT)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:JILL
Last Name:KITTERMAN
Suffix:
Gender:F
Credentials:LPC, CSAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 ESQUIRE TRL APT 10110
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75069-7580
Mailing Address - Country:US
Mailing Address - Phone:817-845-6638
Mailing Address - Fax:
Practice Address - Street 1:17752 PRESTON RD STE 104
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-5794
Practice Address - Country:US
Practice Address - Phone:214-432-0536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76144101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional