Provider Demographics
NPI:1194454660
Name:VITALE, GREGORY JOHN (PSYD)
Entity type:Individual
Prefix:
First Name:GREGORY JOHN
Middle Name:
Last Name:VITALE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 W GORE ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1114
Mailing Address - Country:US
Mailing Address - Phone:321-841-5725
Mailing Address - Fax:321-843-1635
Practice Address - Street 1:14 W GORE ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1114
Practice Address - Country:US
Practice Address - Phone:321-841-5725
Practice Address - Fax:321-843-1635
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007797103G00000X
FLPY12373103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty