Provider Demographics
NPI:1316073133
Name:VITALE, STACY VARGAS (MS MFTI)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:VARGAS
Last Name:VITALE
Suffix:
Gender:F
Credentials:MS MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 N STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-4044
Mailing Address - Country:US
Mailing Address - Phone:626-831-2203
Mailing Address - Fax:626-967-6027
Practice Address - Street 1:1126 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1551
Practice Address - Country:US
Practice Address - Phone:626-967-1667
Practice Address - Fax:626-967-6027
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC49965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist