Provider Demographics
NPI:1558760207
Name:SMITH, VICTORIA MENGHETTI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:MENGHETTI
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
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 6398
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-6398
Mailing Address - Country:US
Mailing Address - Phone:307-699-3996
Mailing Address - Fax:
Practice Address - Street 1:3510 N LAKE CREEK DR
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014-9695
Practice Address - Country:US
Practice Address - Phone:307-699-3996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY650103TC0700X
101YS0200X, 103TC2200X, 103TS0200X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY149920300Medicaid