Provider Demographics
NPI:1033818737
Name:MAGRUDER, VICTORIA NICOLE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:NICOLE
Last Name:MAGRUDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:GREER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:223 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3149
Mailing Address - Country:US
Mailing Address - Phone:618-706-1004
Mailing Address - Fax:
Practice Address - Street 1:100 N MAIN ST STE 8
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1981
Practice Address - Country:US
Practice Address - Phone:618-706-9103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0250851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical