Provider Demographics
NPI:1366023640
Name:VAN WIE, VICTORIA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:VAN WIE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 HIGHWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-3206
Mailing Address - Country:US
Mailing Address - Phone:516-474-8464
Mailing Address - Fax:
Practice Address - Street 1:7 HIGH ST STE 102
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-7605
Practice Address - Country:US
Practice Address - Phone:631-423-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-18
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist