Provider Demographics
NPI:1578687398
Name:WEISS, VICTORIA L (PSY D, L P)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:L
Last Name:WEISS
Suffix:
Gender:F
Credentials:PSY D, L P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 S STEPHENSON AVE STE 212
Mailing Address - Street 2:P.O. BOX 901
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3458
Mailing Address - Country:US
Mailing Address - Phone:906-776-9000
Mailing Address - Fax:906-776-9002
Practice Address - Street 1:427 S STEPHENSON AVE STE 212
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3458
Practice Address - Country:US
Practice Address - Phone:906-776-9000
Practice Address - Fax:906-776-9002
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007240103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM68410Medicare ID - Type Unspecified