Provider Demographics
NPI:1275032021
Name:GAINES, VYCTORIA
Entity Type:Individual
Prefix:
First Name:VYCTORIA
Middle Name:
Last Name:GAINES
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:PO BOX 1066
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-2066
Mailing Address - Country:US
Mailing Address - Phone:706-437-0505
Mailing Address - Fax:706-554-6219
Practice Address - Street 1:727 W 6TH ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-4407
Practice Address - Country:US
Practice Address - Phone:706-437-0505
Practice Address - Fax:706-554-6219
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-22-251258106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician