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General NPI Number Information
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NPI Number | 1477810067
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Entity Type | Individual
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Provider Name | JOHNATHAN VITAL PH.D.
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Gender | Male
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Dates
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Enumeration Date | 04/19/2012
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Last Update Date | 04/20/2012
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Provider Practice Location Address
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Address Line | 2413 ALTENBURG CT
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City | WALDORF
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State | MD
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Zip | 20603
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Country | US
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Telephone | 301-653-8828
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Fax | 202-558-7113
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Provider Business Mailing Address
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Address Line | 2413 ALTENBURG CT
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City | WALDORF
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State | MD
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Zip | 20603
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Country | US
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Telephone | 301-653-8828
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Fax | 202-558-7113
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 04759
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 04759
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | PSY1000614
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License Number State | DC
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY1000614
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License Number State | DC
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