Provider Demographics
NPI:1043080302
Name:VITTER, EVELINA
Entity type:Individual
Prefix:
First Name:EVELINA
Middle Name:
Last Name:VITTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 GRANDE BLVD SE STE E-3
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1799
Mailing Address - Country:US
Mailing Address - Phone:505-585-5113
Mailing Address - Fax:
Practice Address - Street 1:1740 GRANDE BLVD SE STE E-3
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1799
Practice Address - Country:US
Practice Address - Phone:505-585-5113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0014101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health