Provider Demographics
NPI:1811056625
Name:KITTRELL, GARY THOMAS (PHD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:THOMAS
Last Name:KITTRELL
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 1:522 S HILL ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4228
Mailing Address - Country:US
Mailing Address - Phone:770-228-0077
Mailing Address - Fax:
Practice Address - Street 1:604 S 8TH ST # B
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4214
Practice Address - Country:US
Practice Address - Phone:770-228-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001663103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52404519 001OtherBCBS PROVIDER #
GA101343OtherCENPATICO
GA68BBCZJMedicare ID - Type Unspecified