Provider Demographics
NPI:1568976249
Name:CAIN, VICTORIA ANNE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANNE
Last Name:CAIN
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 1:1877 DEL ROBLES DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-6428
Mailing Address - Country:US
Mailing Address - Phone:607-591-1495
Mailing Address - Fax:
Practice Address - Street 1:3460 COUNTRYSIDE BLVD APT 26
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-1338
Practice Address - Country:US
Practice Address - Phone:607-591-1495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017475600Medicaid