Provider Demographics
NPI:1588263776
Name:PITT, MELVIN LEROY JR
Entity type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:LEROY
Last Name:PITT
Suffix:JR
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 1:7108 RIVERBROOKE ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-6199
Mailing Address - Country:US
Mailing Address - Phone:334-294-4062
Mailing Address - Fax:
Practice Address - Street 1:212 W HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1301
Practice Address - Country:US
Practice Address - Phone:850-705-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16179101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health