Provider Demographics
NPI:1174850325
Name:VITALE, ANTONINA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANTONINA
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 FENTON MILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-6923
Mailing Address - Country:US
Mailing Address - Phone:757-758-6635
Mailing Address - Fax:757-282-2546
Practice Address - Street 1:4732 LONGHILL RD
Practice Address - Street 2:SUITE 3202
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-1584
Practice Address - Country:US
Practice Address - Phone:757-758-6635
Practice Address - Fax:757-282-2546
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040072451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497717615OtherVA PREMIER MEDICAID HMO
VA1497717615Medicaid
VA294721OtherVALUE OPTIONS