Healthcare Provider Details

I. General information

NPI: 1194454660
Provider Name (Legal Business Name): GREGORY JOHN VITALE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 W GORE ST
ORLANDO FL
32806-1114
US

IV. Provider business mailing address

14 W GORE ST
ORLANDO FL
32806-1114
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5725
  • Fax: 321-843-1635
Mailing address:
  • Phone: 321-841-5725
  • Fax: 321-843-1635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY12373
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810007797
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: