Provider Demographics
NPI:1508511841
Name:VICTOR, MARLIE
Entity Type:Individual
Prefix:
First Name:MARLIE
Middle Name:
Last Name:VICTOR
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 1:4011 N PINE ISLAND RD APT 202
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-6760
Mailing Address - Country:US
Mailing Address - Phone:754-366-7937
Mailing Address - Fax:
Practice Address - Street 1:4011 N PINE ISLAND RD APT 202
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-6760
Practice Address - Country:US
Practice Address - Phone:754-366-7937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency