Provider Demographics
NPI:1386661841
Name:VITALE, ELIZABETH LEAH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:LEAH
Last Name:VITALE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:682 PROSPECT AVE.
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-4238
Mailing Address - Country:US
Mailing Address - Phone:860-523-9011
Mailing Address - Fax:860-523-9011
Practice Address - Street 1:682 PROSPECT AVE.
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4238
Practice Address - Country:US
Practice Address - Phone:860-523-9011
Practice Address - Fax:860-523-9011
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT001898103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist