Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | 46TR00508800 | NJ |
Y | 225XG0600X | Occupational Therapist - Gerontology | 46TR00508800 | NJ |
NPI | 1639496045 |
---|---|
Provider Name | Mrs. Diane Vitillo |
First Address | Kendall Park, NJ 08824-7013 |
Second Address | Kendall Park, NJ 08824-7013 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2010 |
Last Update Date | 07/06/2010 |