Provider Demographics
NPI:1376896092
Name:BATES, VICTORIA R WALLACE (MS-CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:R WALLACE
Last Name:BATES
Suffix:
Gender:F
Credentials:MS-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:P.O. BOX 240
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014
Mailing Address - Country:US
Mailing Address - Phone:307-733-8210
Mailing Address - Fax:
Practice Address - Street 1:3850 N. WILDERNESS DR.
Practice Address - Street 2:
Practice Address - City:TETON VILLAGE
Practice Address - State:WY
Practice Address - Zip Code:83025
Practice Address - Country:US
Practice Address - Phone:307-733-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist