Provider Demographics
NPI:1033371208
Name:PENNOCK, VICTORIA RUTH (CMT)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:RUTH
Last Name:PENNOCK
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 FORT MASON DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-2313
Mailing Address - Country:US
Mailing Address - Phone:512-906-9734
Mailing Address - Fax:
Practice Address - Street 1:11308 WET SEASON DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-5855
Practice Address - Country:US
Practice Address - Phone:512-906-9734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108294225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist