Provider Demographics
NPI:1205101177
Name:PITTMAN, DANA DURST (SLP)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:DURST
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4667 BAYOU BLACK DR
Mailing Address - Street 2:
Mailing Address - City:GIBSON
Mailing Address - State:LA
Mailing Address - Zip Code:70356-3312
Mailing Address - Country:US
Mailing Address - Phone:601-630-5564
Mailing Address - Fax:
Practice Address - Street 1:4667 BAYOU BLACK DR
Practice Address - Street 2:
Practice Address - City:GIBSON
Practice Address - State:LA
Practice Address - Zip Code:70356-3312
Practice Address - Country:US
Practice Address - Phone:601-630-5564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 6496235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist