Provider Demographics
NPI:1851826796
Name:BOURDON, VICTORIA (LMSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BOURDON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 PALMETTO PK BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7968
Mailing Address - Country:US
Mailing Address - Phone:803-724-7405
Mailing Address - Fax:
Practice Address - Street 1:108 PALMETTO PK BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7968
Practice Address - Country:US
Practice Address - Phone:803-724-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical