MEDICARE: MRS. DENETTE L. VITAL RN, M.A., LPC

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	101YP2500X	Professional Counselor	60854	TX

General Provider Information

NPI Number	:	1093909590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DENETTE L. VITAL RN, M.A., LPC

Provider Business Mailing Address
First Line	:	100 N CENTRAL EXPY
Second Line	:	SUITE 400-8
City	:	DALLAS
State	:	TX
Zip	:	75201-4312
Country	:	US
Telephone Number	:	469-658-5457
Fax Number	:	469-227-4251

Provider Business Practice Location Address
First Line	:	100 N CENTRAL EXPY
Second Line	:	SUITE 400-8
City	:	DALLAS
State	:	TX
Zip	:	75201-4312
Country	:	US
Telephone Number	:	469-658-5457
Fax Number	:	469-227-4251

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	08/28/2007

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