Basic Information
| Provider Information | |||||||||
| NPI: | 1063914497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VITULLO | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOBLEY | ||||||||
| OtherFirstName: | KAYLA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5982 RHODES RD | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442408100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306731347 | ||||||||
| FaxNumber: | 3306783677 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 ARCH ST STE 1B | ||||||||
| Address2: | |||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303754679 | ||||||||
| FaxNumber: | 3303757779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1201163 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.