Provider Demographics
NPI:1639563018
Name:GRANDE, VICTORIA (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:
Last Name:GRANDE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2252
Mailing Address - Country:US
Mailing Address - Phone:631-716-5425
Mailing Address - Fax:
Practice Address - Street 1:348 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780
Practice Address - Country:US
Practice Address - Phone:631-716-5424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008573101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health