Provider Demographics
NPI:1700104999
Name:VITALE, MARJI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARJI
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2105
Mailing Address - Country:US
Mailing Address - Phone:860-521-8035
Mailing Address - Fax:
Practice Address - Street 1:1038 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2109
Practice Address - Country:US
Practice Address - Phone:860-313-1119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002529103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical