Provider Demographics
NPI:1891139614
Name:DE VITO, MICHELE A (NCTMB, LMT)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:DE VITO
Suffix:
Gender:F
Credentials:NCTMB, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9727
Mailing Address - Country:US
Mailing Address - Phone:973-615-6519
Mailing Address - Fax:
Practice Address - Street 1:207 MAIN RD
Practice Address - Street 2:
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9727
Practice Address - Country:US
Practice Address - Phone:973-615-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00470800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist