Provider Demographics
NPI:1235674235
Name:VICTORIA, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:VICTORIA
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 1:1467 FORD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-3911
Mailing Address - Country:US
Mailing Address - Phone:909-583-4040
Mailing Address - Fax:
Practice Address - Street 1:1467 FORD ST STE 104
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-3911
Practice Address - Country:US
Practice Address - Phone:909-583-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst