Provider Demographics
NPI:1750899472
Name:PITTMAN, KELLIE MARIE (BCABA)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 E SOUTHPORT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7874
Mailing Address - Country:US
Mailing Address - Phone:317-796-6668
Mailing Address - Fax:317-759-2557
Practice Address - Street 1:1800 W 900 S
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:IN
Practice Address - Zip Code:47234-9773
Practice Address - Country:US
Practice Address - Phone:317-512-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0-17-7999106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst