Individual
DR. JOHNATHAN VITAL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
2413 ALTENBURG CT, WALDORF, MD 20603
(301) 653-8828
(202) 558-7113
Mailing address
2413 ALTENBURG CT, WALDORF, MD 20603
(301) 653-8828
(202) 558-7113
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
04759
MD
103G00000X
Clinical Neuropsychologist
PSY1000614
DC
103T00000X
Psychologist
04759
MD
103T00000X
Psychologist
PSY1000614
DC
Other
Enumeration date
04/19/2012
Last updated
04/20/2012
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