Provider Demographics
NPI:1104188655
Name:ITTY, NISY (MHS, CRC)
Entity type:Individual
Prefix:MS
First Name:NISY
Middle Name:
Last Name:ITTY
Suffix:
Gender:F
Credentials:MHS, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 BRIDGE CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4726
Mailing Address - Country:US
Mailing Address - Phone:321-217-3641
Mailing Address - Fax:
Practice Address - Street 1:315 N LAKEMONT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3205
Practice Address - Country:US
Practice Address - Phone:407-830-6412
Practice Address - Fax:407-830-8413
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00111018101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor