Provider Demographics
NPI:1093330656
Name:EDELSTEIN, VICTORIA RUTH
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:RUTH
Last Name:EDELSTEIN
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 1:316 MID VALLEY CTR STE 186
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-8516
Mailing Address - Country:US
Mailing Address - Phone:916-337-4052
Mailing Address - Fax:
Practice Address - Street 1:32650 STATE ROUTE 20 STE E204
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-2686
Practice Address - Country:US
Practice Address - Phone:360-279-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1171406826OtherTRICARE