Provider Demographics
NPI:1548631005
Name:VITEO, ROXANNE LEIA (PTA)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:LEIA
Last Name:VITEO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:
Other - Last Name:UNDERCUFFLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 MARTER AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3114
Mailing Address - Country:US
Mailing Address - Phone:856-291-4800
Mailing Address - Fax:
Practice Address - Street 1:212 MARTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3114
Practice Address - Country:US
Practice Address - Phone:856-291-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00294000225200000X
MDA3897225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant