Basic Information
| Provider Information | |||||||||
| NPI: | 1649815804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PITTS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | BRIANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21920 HARDING ST | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482372540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487619197 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2630 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132597990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2019 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502006068 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.