Provider Demographics
NPI:1922165570
Name:VICTA, STEPHANIE JEAN (LMT)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:JEAN
Last Name:VICTA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 19TH AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-6063
Mailing Address - Country:US
Mailing Address - Phone:561-628-6412
Mailing Address - Fax:561-588-9583
Practice Address - Street 1:1507 19TH AVE N
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-6063
Practice Address - Country:US
Practice Address - Phone:561-628-6412
Practice Address - Fax:561-588-9583
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30142225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist