Provider Demographics
NPI:1104180546
Name:CLARK, VICTORIA CAROL (MS SPECIAL ED)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:CAROL
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS SPECIAL ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SNEDECKER AVE
Mailing Address - Street 2:
Mailing Address - City:CONGERS
Mailing Address - State:NY
Mailing Address - Zip Code:10920-1808
Mailing Address - Country:US
Mailing Address - Phone:845-268-0316
Mailing Address - Fax:
Practice Address - Street 1:155 PHILLIPS HILL RD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-4129
Practice Address - Country:US
Practice Address - Phone:845-708-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1199846174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist