Basic Information
| Provider Information | |||||||||
| NPI: | 1003282641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PITTMAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS,PCMHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 HIGHWAY 80 W | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390564108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014732106 | ||||||||
| FaxNumber: | 6014732150 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 HIGHWAY 80 W | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390564108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014732106 | ||||||||
| FaxNumber: | 6014732150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2015 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MS | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00018209 | 05 | MS | MEDICAID |