Provider Demographics
NPI:1629671748
Name:BLACKSMITH, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BLACKSMITH
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 1:736 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4122
Mailing Address - Country:US
Mailing Address - Phone:530-867-6287
Mailing Address - Fax:
Practice Address - Street 1:2715 K ST STE C
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5128
Practice Address - Country:US
Practice Address - Phone:916-573-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94025734103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical