MEDICARE: LIZA J VITIELLO MA, LMHC

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	101YM0800X	Mental Health Counselor	MH 7957	FL

General Provider Information

NPI Number	:	1710092382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZA J VITIELLO MA, LMHC

Provider Business Mailing Address
First Line	:	1342 COLONIAL BLVD
Second Line	:	BUILDING B, SUITE13
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1013
Country	:	US
Telephone Number	:	239-931-4444
Fax Number	:	239-931-4440

Provider Business Practice Location Address
First Line	:	1342 COLONIAL BLVD
Second Line	:	BUILDING B, SUITE13
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1013
Country	:	US
Telephone Number	:	239-931-4444
Fax Number	:	239-931-4440

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/09/2007

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