Provider Demographics
NPI:1285145722
Name:PITTS, NIESHA GWENDOLYN
Entity type:Individual
Prefix:MRS
First Name:NIESHA
Middle Name:GWENDOLYN
Last Name:PITTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 N 62ND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-3207
Mailing Address - Country:US
Mailing Address - Phone:215-359-6334
Mailing Address - Fax:
Practice Address - Street 1:8400 BUSTLETON AVE STE 6
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-1918
Practice Address - Country:US
Practice Address - Phone:215-728-4930
Practice Address - Fax:215-728-4980
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health