Provider Demographics
NPI:1144316720
Name:VITELA, TONY HERNAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:HERNAN
Last Name:VITELA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 BROADWAY, SUITE 235
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-5746
Mailing Address - Country:US
Mailing Address - Phone:210-930-5893
Mailing Address - Fax:210-822-0024
Practice Address - Street 1:5108 BROADWAY, SUITE 235
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-5746
Practice Address - Country:US
Practice Address - Phone:210-930-5893
Practice Address - Fax:210-822-0024
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX248621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063866001Medicaid
TX24862OtherLICENSE