Provider Demographics
NPI:1912144957
Name:ITTLEMAN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ITTLEMAN
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 1:8739 ORCHARD RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-2768
Mailing Address - Country:US
Mailing Address - Phone:832-233-2601
Mailing Address - Fax:
Practice Address - Street 1:8739 ORCHARD RIDGE LN
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-2768
Practice Address - Country:US
Practice Address - Phone:832-233-2601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19613235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist