Healthcare Provider Details

I. General information

NPI: 1831621291
Provider Name (Legal Business Name): VITALITY FRP MULTIDISCIPLINARY PSYCHOLOGY AND PHYSIOTHERAPY FOR CHRONI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 LEAD HILL BLVD
ROSEVILLE CA
95661-3061
US

IV. Provider business mailing address

1640 AINSDALE DR
ROSEVILLE CA
95747-5838
US

V. Phone/Fax

Practice location:
  • Phone: 510-967-2474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21758
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT19666
License Number StateCA

VIII. Authorized Official

Name: HEATHER MARTARELLA
Title or Position: PRESIDENT
Credential:
Phone: 510-967-2474