Provider Demographics
NPI:1356401541
Name:VITELLO, NANCY
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:VITELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N COLLEGE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3933
Mailing Address - Country:US
Mailing Address - Phone:812-335-4148
Mailing Address - Fax:
Practice Address - Street 1:115 N COLLEGE AVE STE 113
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3933
Practice Address - Country:US
Practice Address - Phone:812-335-4148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000158A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
7166248OtherAETNA PIN
000000191123OtherANTHEM PIN