Provider Demographics
NPI:1326613589
Name:DEWATERS, VICTORIA MICHELE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MICHELE
Last Name:DEWATERS
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 101
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33780-0101
Mailing Address - Country:US
Mailing Address - Phone:727-804-1442
Mailing Address - Fax:727-491-5508
Practice Address - Street 1:8790 53RD WAY N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782-5180
Practice Address - Country:US
Practice Address - Phone:727-804-1442
Practice Address - Fax:727-491-5508
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022082900Medicaid