Provider Demographics
NPI:1619552460
Name:COMBS, VICTORIA MADELINE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MADELINE
Last Name:COMBS
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 1:116 BONNER PL
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28307-2355
Mailing Address - Country:US
Mailing Address - Phone:217-260-3613
Mailing Address - Fax:
Practice Address - Street 1:941A S MCPHERSON CHURCH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5369
Practice Address - Country:US
Practice Address - Phone:910-286-4784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBACB543233106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician