Provider Demographics
NPI:1376201061
Name:VITAL, GERALD (BA, CBHCM)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:
Last Name:VITAL
Suffix:
Gender:M
Credentials:BA, CBHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NE 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-6034
Mailing Address - Country:US
Mailing Address - Phone:305-915-8900
Mailing Address - Fax:
Practice Address - Street 1:1400 NE 125TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-6034
Practice Address - Country:US
Practice Address - Phone:305-915-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator