Provider Demographics
NPI:1073690608
Name:MCCAIN, VICTORIA M (PHD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:M
Last Name:MCCAIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:J
Other - Last Name:MCCAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:801 7TH AVE
Mailing Address - Street 2:REVENUE MANAGEMENT
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2733
Mailing Address - Country:US
Mailing Address - Phone:682-885-4157
Mailing Address - Fax:682-885-1903
Practice Address - Street 1:1516 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-1480
Practice Address - Fax:682-885-3600
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30569103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124163OtherSUPERIOR PIN
TX75205164617OtherPBH PIN
TX10013975OtherAMERIGROUP PIN
TX2241238OtherFIRSTHEALTH PIN
TX165067301Medicaid
TX00G981OtherBCBSTX GRP PIN
1336198894OtherGRP NPI NUMBER
TX86922AOtherBCBSTX IND PIN