Provider Demographics
NPI:1972197408
Name:PELTON, VICTORIA ROSE (LMT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ROSE
Last Name:PELTON
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 1:11679 COCOA CT
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-3023
Mailing Address - Country:US
Mailing Address - Phone:586-746-9789
Mailing Address - Fax:
Practice Address - Street 1:11679 COCOA CT
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-3023
Practice Address - Country:US
Practice Address - Phone:586-746-9789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011201225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist