Provider Demographics
NPI:1629586870
Name:VITALE, MICHAEL JOSEPH (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:VITALE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18643-2101
Mailing Address - Country:US
Mailing Address - Phone:570-498-6340
Mailing Address - Fax:
Practice Address - Street 1:22 EAST ST STE 2
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-1100
Practice Address - Country:US
Practice Address - Phone:570-335-0357
Practice Address - Fax:570-569-2453
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005212L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist