Provider Demographics
NPI:1831661792
Name:PITTMAN, SHADD
Entity type:Individual
Prefix:
First Name:SHADD
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 1:302 RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-3942
Mailing Address - Country:US
Mailing Address - Phone:985-732-2089
Mailing Address - Fax:985-732-2078
Practice Address - Street 1:302 RICHMOND ST
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3942
Practice Address - Country:US
Practice Address - Phone:985-732-2089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782670171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator