=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780774877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK J VITALE LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3375 PARK AVE SUITE 4001
-----------------------------------------------------
City | WANTAGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11793-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-238-1251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3375 PARK AVE SUITE 4001
-----------------------------------------------------
City | WANTAGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11793-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-238-1251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R054548
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------