Healthcare Provider Details

I. General information

NPI: 1972050854
Provider Name (Legal Business Name): GARY JOHN VITALI ED.D., NBC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 LEXINGTON ST
VERSAILLES KY
40383-1240
US

IV. Provider business mailing address

290 LEXINGTON ST
VERSAILLES KY
40383-1240
US

V. Phone/Fax

Practice location:
  • Phone: 859-873-5656
  • Fax:
Mailing address:
  • Phone: 859-873-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number141393
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number100738
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: