Provider Demographics
NPI:1689950578
Name:VITALE, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARO
Other - Middle Name:
Other - Last Name:VITALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:702 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4243
Mailing Address - Country:US
Mailing Address - Phone:831-239-9983
Mailing Address - Fax:
Practice Address - Street 1:501 MISSION ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060
Practice Address - Country:US
Practice Address - Phone:831-460-6462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87385106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92069ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#