Healthcare Provider Details

I. General information

NPI: 1689086068
Provider Name (Legal Business Name): KERRI VITOLO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 ROCKY HILL RD
NEW FAIRFIELD CT
06812-2726
US

IV. Provider business mailing address

53 ROCKY HILL RD
NEW FAIRFIELD CT
06812-2726
US

V. Phone/Fax

Practice location:
  • Phone: 203-733-1190
  • Fax:
Mailing address:
  • Phone: 203-733-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1156201
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-15122
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: