MEDICARE: DR. ELIZABETH LEAH VITALE PSYD

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	103T00000X	Psychologist	CT001898	CT

General Provider Information

NPI Number	:	1386661841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH LEAH VITALE PSYD

Provider Business Mailing Address
First Line	:	682 PROSPECT AVE.
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06105-4238
Country	:	US
Telephone Number	:	860-523-9011
Fax Number	:	860-523-9011

Provider Business Practice Location Address
First Line	:	682 PROSPECT AVE.
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06105-4238
Country	:	US
Telephone Number	:	860-523-9011
Fax Number	:	860-523-9011

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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