Provider Demographics
NPI:1366208944
Name:VITAL, IMANI
Entity type:Individual
Prefix:
First Name:IMANI
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 1:4620 N BRAESWOOD BLVD APT 229
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-2854
Mailing Address - Country:US
Mailing Address - Phone:682-500-9273
Mailing Address - Fax:
Practice Address - Street 1:20008 CHAMPION FOREST DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-8694
Practice Address - Country:US
Practice Address - Phone:713-240-1837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator