Provider Demographics
NPI:1982169041
Name:VITALE, GINA (PTA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CUMMINGS CENTER
Mailing Address - Street 2:166 D
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-712-3370
Mailing Address - Fax:978-922-4416
Practice Address - Street 1:100 CUMMINGS CTR STE 166D
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6135
Practice Address - Country:US
Practice Address - Phone:978-712-3370
Practice Address - Fax:978-922-4416
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7703225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant