Provider Demographics
NPI:1124865290
Name:VITALE, ALEXIS ROSE (OTD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ROSE
Last Name:VITALE
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 E BROOKLYN VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3396
Mailing Address - Country:US
Mailing Address - Phone:315-406-6434
Mailing Address - Fax:
Practice Address - Street 1:4009 CRAIG AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2505
Practice Address - Country:US
Practice Address - Phone:704-365-2620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16835225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist