Provider Demographics
NPI:1720154362
Name:VITALE, CONSTANCE (MA)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 PARK AVE W APT 430
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2253
Mailing Address - Country:US
Mailing Address - Phone:773-315-3625
Mailing Address - Fax:
Practice Address - Street 1:1250 PARK AVE W APT 430
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2253
Practice Address - Country:US
Practice Address - Phone:773-315-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-001120101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor