Provider Demographics
NPI:1902120900
Name:ITTNER, PAMELA JOAN (PMH)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:JOAN
Last Name:ITTNER
Suffix:
Gender:F
Credentials:PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2659 W GIFFORD LN
Mailing Address - Street 2:
Mailing Address - City:CITRUS SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34433-7109
Mailing Address - Country:US
Mailing Address - Phone:918-740-1366
Mailing Address - Fax:
Practice Address - Street 1:1009 MAITLAND CENTER COMMONS BLVD
Practice Address - Street 2:#212
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7270
Practice Address - Country:US
Practice Address - Phone:800-840-2528
Practice Address - Fax:407-636-3530
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3899101YM0800X
FL1295101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0141785-00Medicaid