Provider Demographics
NPI:1417373317
Name:VICITAL, CATHERINE
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:VICITAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2346 125TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-2622
Mailing Address - Country:US
Mailing Address - Phone:347-306-6778
Mailing Address - Fax:
Practice Address - Street 1:2346 125TH ST
Practice Address - Street 2:
Practice Address - City:COLLEGE POINT
Practice Address - State:NY
Practice Address - Zip Code:11356-2622
Practice Address - Country:US
Practice Address - Phone:347-306-6778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-15
Last Update Date:2014-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services