Provider Demographics
NPI:1568790335
Name:VICTORY, LYNN A (MA, RD, LD, LPC)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:A
Last Name:VICTORY
Suffix:
Gender:F
Credentials:MA, RD, LD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 PETTIGRU STREET
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601
Mailing Address - Country:US
Mailing Address - Phone:864-631-1035
Mailing Address - Fax:864-631-1067
Practice Address - Street 1:710 PETTIGRU STREET
Practice Address - Street 2:THE COTTAGE
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601
Practice Address - Country:US
Practice Address - Phone:864-631-1035
Practice Address - Fax:864-631-1067
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-06
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC415133V00000X
SC5461101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered