Provider Demographics
NPI:1821424706
Name:VITALE, AMY A (MS,BA,LADC,LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:VITALE
Suffix:
Gender:F
Credentials:MS,BA,LADC,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W MAIN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-4032
Mailing Address - Country:US
Mailing Address - Phone:203-779-6784
Mailing Address - Fax:
Practice Address - Street 1:250 W MAIN ST STE 301
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-4032
Practice Address - Country:US
Practice Address - Phone:203-779-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3129101YM0800X
CT972101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12653171OtherCAQH
CT008049844Medicaid
CT4795938OtherCIGNA BEHAVIORAL HEALLTH
CT060669107OtherUNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY
CT060669107OtherUBH-CONNECTICARE WELLMORE GRP/FACILITY
CT060669107OtherUBH-FREEDOM/LIBERTY OXFORD HEALTH PLANS WELLMORE GRP/FACILITY
CT5263966OtherAETNA BEHAVIORAL HEALTH
CTNOT ELIGIBLEMedicare PIN
CT12653171OtherCAQH
CT008049844Medicaid
CT060669107OtherUBH-UNITED HEALTH CARE WELLMORE GRP/FACILITY
CT060669107OtherANTHEM BCBS OF CT WELLMORE GRP/FACILITY
CTD339210 -WTBY 402OtherVALUE OPTIONS
CT060669107OtherHEALTHYCT WELLMORE GRP/FACILIGY