Provider Demographics
NPI:1164447652
Name:VITALE, REBECCA A (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:VITALE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:POIROT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-651-0444
Mailing Address - Fax:618-654-5439
Practice Address - Street 1:15 APEX DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1282
Practice Address - Country:US
Practice Address - Phone:618-651-0444
Practice Address - Fax:618-654-5439
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP88612Medicare UPIN