Provider Demographics
NPI:1902068869
Name:PITALUGA, ANTHONY JESUS (LMHC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JESUS
Last Name:PITALUGA
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 SOUTH HAWTHORNE ROAD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-1097
Mailing Address - Country:US
Mailing Address - Phone:336-716-0800
Mailing Address - Fax:336-716-0822
Practice Address - Street 1:403 SOUTH HAWTHORNE ROAD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-1097
Practice Address - Country:US
Practice Address - Phone:336-716-0800
Practice Address - Fax:336-716-0822
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6404101YM0800X
NC6983101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003140700Medicaid