MEDICARE: VITALITY COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083330393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALITY COUNSELING LLC

Provider Business Mailing Address
First Line	:	3305 W BANCROFT ST
Second Line	:
City	:	OTTAWA HILLS
State	:	OH
Zip	:	43606-2601
Country	:	US
Telephone Number	:	419-461-1983
Fax Number	:

Provider Business Practice Location Address
First Line	:	3305 W BANCROFT ST
Second Line	:
City	:	OTTAWA HILLS
State	:	OH
Zip	:	43606-2601
Country	:	US
Telephone Number	:	419-461-1983
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH E BERGMAN
Credential	:	LPCC
Telephone Number	:	419-461-1983

Provider Enumeration Date	:	10/18/2022
Last Update Date	:	10/18/2022

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Directions to “VITALITY COUNSELING LLC ” Practice Location

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