Provider Demographics
NPI:1629269576
Name:VITALE, SHARON ROSE (MA)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:ROSE
Last Name:VITALE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24609 CULVER ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3124
Mailing Address - Country:US
Mailing Address - Phone:248-631-6703
Mailing Address - Fax:
Practice Address - Street 1:1200 N TELEGRAPH RD BLDG 32
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1032
Practice Address - Country:US
Practice Address - Phone:248-456-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009025101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
6401009025OtherSTATE LICENSURE NUMBER