Provider Demographics
NPI:1285741207
Name:ITALIA, MICHAEL A (MA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:ITALIA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 MAIN ST
Mailing Address - Street 2:SUITE 704
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-3040
Mailing Address - Country:US
Mailing Address - Phone:802-254-5875
Mailing Address - Fax:
Practice Address - Street 1:139 MAIN ST
Practice Address - Street 2:SUITE 704
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-3040
Practice Address - Country:US
Practice Address - Phone:802-254-5875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT419103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist