Provider Demographics
NPI:1629581129
Name:IVENS, VICTORIA (DPT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:IVENS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:OLDANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-541-3735
Practice Address - Street 1:1060 EAGLES LANDING PKWY STE 130
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9091
Practice Address - Country:US
Practice Address - Phone:470-369-5770
Practice Address - Fax:470-369-5771
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015181225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist