Provider Demographics
NPI:1457452104
Name:VITALE, TERESA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:VITALE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17280 BUCKTHORN DR
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-1412
Mailing Address - Country:US
Mailing Address - Phone:440-463-6606
Mailing Address - Fax:440-543-5120
Practice Address - Street 1:17280 BUCKTHORN DR
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44023-1412
Practice Address - Country:US
Practice Address - Phone:440-463-6606
Practice Address - Fax:440-543-5120
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP T 08117174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHVI4129031Medicare UPIN