Provider Demographics
NPI:1982443370
Name:PITTMAN, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3467 FLAT RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32443-2057
Mailing Address - Country:US
Mailing Address - Phone:850-450-6793
Mailing Address - Fax:
Practice Address - Street 1:8317 FRONT BEACH RD STE 23
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-4893
Practice Address - Country:US
Practice Address - Phone:850-886-0441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24349068106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty