Provider Demographics
NPI:1144621715
Name:SMITH, VICTORIA R
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:R
Last Name:SMITH
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 1:1201 N 15TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-1989
Mailing Address - Country:US
Mailing Address - Phone:304-624-6554
Mailing Address - Fax:304-624-5223
Practice Address - Street 1:RR 2 BOX 157
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-9618
Practice Address - Country:US
Practice Address - Phone:304-624-6554
Practice Address - Fax:304-624-5223
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool