Provider Demographics
NPI:1528347366
Name:PITTRELL, KIZZY DIANNA (EDD, LCPC)
Entity type:Individual
Prefix:DR
First Name:KIZZY
Middle Name:DIANNA
Last Name:PITTRELL
Suffix:
Gender:F
Credentials:EDD, LCPC
Other - Prefix:MS
Other - First Name:KIZZY
Other - Middle Name:DIANNA
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDD, LCPC
Mailing Address - Street 1:1120 MIDDLE RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220
Mailing Address - Country:US
Mailing Address - Phone:301-609-9887
Mailing Address - Fax:301-609-7284
Practice Address - Street 1:1120 MIDDLE RIVER ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220
Practice Address - Country:US
Practice Address - Phone:443-868-7762
Practice Address - Fax:443-868-7643
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589561800Medicaid