Provider Demographics
NPI:1770113292
Name:GITTNER, CALVIN H
Entity type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:H
Last Name:GITTNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4662 CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-7450
Mailing Address - Country:US
Mailing Address - Phone:386-451-1008
Mailing Address - Fax:
Practice Address - Street 1:4662 CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-7450
Practice Address - Country:US
Practice Address - Phone:386-451-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3285106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist