Provider Demographics
NPI:1790565729
Name:VITALE, MARK (LAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:VITALE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 FORD RD
Mailing Address - Street 2:
Mailing Address - City:LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:07850-1650
Mailing Address - Country:US
Mailing Address - Phone:201-486-6308
Mailing Address - Fax:
Practice Address - Street 1:181 NEW RD
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-5625
Practice Address - Country:US
Practice Address - Phone:973-939-4984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00746800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health