Provider Demographics
NPI:1073915153
Name:WALLIN, VICTORIA (ATC/L,ACSM-CPT)
Entity Type:Individual
Prefix:MISS
First Name:VICTORIA
Middle Name:
Last Name:WALLIN
Suffix:
Gender:F
Credentials:ATC/L,ACSM-CPT
Other - Prefix:MRS
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC/L, ACSM-CPT
Mailing Address - Street 1:2221 HAMPTON DR
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2460
Mailing Address - Country:US
Mailing Address - Phone:574-329-2386
Mailing Address - Fax:
Practice Address - Street 1:2221 HAMPTON DR
Practice Address - Street 2:APARTMENT 4
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2460
Practice Address - Country:US
Practice Address - Phone:574-329-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-21
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002230A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer