Provider Demographics
NPI:1417363292
Name:SEPULVEDA, VICTORIA IRENE MILLER (PHD, LPC, CSAC, NC)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:IRENE MILLER
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:PHD, LPC, CSAC, NC
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 171009
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-8092
Mailing Address - Country:US
Mailing Address - Phone:414-837-6392
Mailing Address - Fax:
Practice Address - Street 1:116 W GRAND AVE STE 104
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2242
Practice Address - Country:US
Practice Address - Phone:262-394-1829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15861-132101YA0400X
WI5482-125101YP2500X
MI2-01182101YA0400X
OHC.0600123101YP2500X
MI6401013308101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)