Provider Demographics
NPI:1972050854
Name:VITALI, GARY JOHN (EDD, NBC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:JOHN
Last Name:VITALI
Suffix:
Gender:M
Credentials:EDD, NBC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 LEXINGTON ST
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1240
Mailing Address - Country:US
Mailing Address - Phone:859-873-5656
Mailing Address - Fax:
Practice Address - Street 1:290 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1240
Practice Address - Country:US
Practice Address - Phone:859-873-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY141393235Z00000X
KY100738237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist