Provider Demographics
NPI:1568825594
Name:FONDALE, VICTORIA (MSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:FONDALE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2329
Mailing Address - Country:US
Mailing Address - Phone:304-425-9541
Mailing Address - Fax:304-425-1332
Practice Address - Street 1:200 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2329
Practice Address - Country:US
Practice Address - Phone:304-425-9541
Practice Address - Fax:304-425-1332
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944668101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005489001Medicaid
WV0005489002Medicaid