Provider Demographics
NPI:1154650182
Name:FRY, VICTORIA LYNN (MA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:FRY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14224 E 36TH ST S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-3467
Mailing Address - Country:US
Mailing Address - Phone:636-359-1611
Mailing Address - Fax:
Practice Address - Street 1:1000 E 24TH ST STE 2E
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2776
Practice Address - Country:US
Practice Address - Phone:816-404-5850
Practice Address - Fax:816-404-6049
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009038376101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499454809Medicaid