Provider Demographics
NPI:1699193672
Name:PETERSON-VITA, ELIZABETH ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:PETERSON-VITA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 EAST STONEWALL STREET
Mailing Address - Street 2:SUITE 714
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202
Mailing Address - Country:US
Mailing Address - Phone:980-314-4030
Mailing Address - Fax:
Practice Address - Street 1:700 EAST STONEWALL STREET
Practice Address - Street 2:SUITE 714
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202
Practice Address - Country:US
Practice Address - Phone:980-314-4030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008026103T00000X
NC2683103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist