Provider Demographics
NPI:1710092382
Name:VITIELLO, LIZA J (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:J
Last Name:VITIELLO
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 COLONIAL BLVD
Mailing Address - Street 2:BUILDING B, SUITE13
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1013
Mailing Address - Country:US
Mailing Address - Phone:239-931-4444
Mailing Address - Fax:239-931-4440
Practice Address - Street 1:1342 COLONIAL BLVD
Practice Address - Street 2:BUILDING B, SUITE13
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1013
Practice Address - Country:US
Practice Address - Phone:239-931-4444
Practice Address - Fax:239-931-4440
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 7957101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ063EMedicare UPIN