1174850325 NPI number — ANTONINA VITALE L.C.S.W.

Table of content: ANTONINA VITALE L.C.S.W. (NPI 1174850325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174850325 NPI number — ANTONINA VITALE L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VITALE
Provider First Name:
ANTONINA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174850325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4951 FENTON MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23188-6923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-758-6635
Provider Business Mailing Address Fax Number:
757-282-2546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4732 LONGHILL RD
Provider Second Line Business Practice Location Address:
SUITE 3202
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23188-1584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-758-6635
Provider Business Practice Location Address Fax Number:
757-282-2546
Provider Enumeration Date:
11/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904007245 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1497717615 . This is a "VA PREMIER MEDICAID HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1497717615 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 294721 . This is a "VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com