Provider Demographics
NPI:1801558770
Name:VITALE, LEANN RENEE (OT)
Entity type:Individual
Prefix:
First Name:LEANN
Middle Name:RENEE
Last Name:VITALE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 ALABAMA CIR
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2029
Mailing Address - Country:US
Mailing Address - Phone:714-406-3447
Mailing Address - Fax:
Practice Address - Street 1:3324 ALABAMA CIR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2029
Practice Address - Country:US
Practice Address - Phone:609-338-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16263225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist