Provider Demographics
NPI:1073492146
Name:VITAL, IVETTE
Entity type:Individual
Prefix:
First Name:IVETTE
Middle Name:
Last Name:VITAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14801 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:BALCH SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75180-4353
Mailing Address - Country:US
Mailing Address - Phone:469-662-1815
Mailing Address - Fax:
Practice Address - Street 1:1501 N HAMPTON RD
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2301
Practice Address - Country:US
Practice Address - Phone:469-659-7216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBACB1229425106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician