Provider Demographics
NPI:1437310679
Name:STAR, VICTORIA LEE (BSSW)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:LEE
Last Name:STAR
Suffix:
Gender:F
Credentials:BSSW
Other - Prefix:MRS
Other - First Name:VICTORIA
Other - Middle Name:LEE
Other - Last Name:YOUNGBIRD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0020
Mailing Address - Country:US
Mailing Address - Phone:541-278-3766
Mailing Address - Fax:
Practice Address - Street 1:46314 TIMINE WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:541-278-7572
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR02-03-63101YA0400X
OR020363101YA0400X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR171037Medicaid