Provider Demographics
NPI:1548615818
Name:VICTORY CLINICAL SERVICES
Entity Type:Organization
Organization Name:VICTORY CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISIOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EHART
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CAADC
Authorized Official - Phone:517-784-2929
Mailing Address - Street 1:3300 LANSING AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1621
Mailing Address - Country:US
Mailing Address - Phone:517-784-2929
Mailing Address - Fax:
Practice Address - Street 1:3300 LANSING AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1621
Practice Address - Country:US
Practice Address - Phone:517-784-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty