Provider Demographics
NPI:1750592697
Name:VITALE, KATHERINE ANNE (PT)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ANNE
Last Name:VITALE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40319 SADDLEWOOD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313
Mailing Address - Country:US
Mailing Address - Phone:586-247-9509
Mailing Address - Fax:
Practice Address - Street 1:27450 SCHOENHERR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088
Practice Address - Country:US
Practice Address - Phone:586-582-7825
Practice Address - Fax:586-582-7826
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003797225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5171931Medicaid
MI5171931Medicaid