Healthcare Provider Details

I. General information

NPI: 1033512298
Provider Name (Legal Business Name): GIOVANNI VITALE II LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23061 NONA ST
DEARBORN MI
48124-2623
US

IV. Provider business mailing address

930 BEECHMONT ST
DEARBORN MI
48124-1513
US

V. Phone/Fax

Practice location:
  • Phone: 313-969-7750
  • Fax:
Mailing address:
  • Phone: 313-969-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6361000868
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: