Provider Demographics
NPI:1598903841
Name:VICTORIA, EDITHA (PT)
Entity Type:Individual
Prefix:
First Name:EDITHA
Middle Name:
Last Name:VICTORIA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 SOMERS AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-2607
Mailing Address - Country:US
Mailing Address - Phone:917-459-8033
Mailing Address - Fax:201-244-6632
Practice Address - Street 1:49 SOMERS AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-2607
Practice Address - Country:US
Practice Address - Phone:917-459-8033
Practice Address - Fax:201-244-6632
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-24
Last Update Date:2009-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0184352251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics