Provider Demographics
NPI:1972916443
Name:HAESELBARTH, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:HAESELBARTH
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:PO BOX 2351
Mailing Address - Street 2:10 BENNETT WAY
Mailing Address - City:EDGARTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02539-2351
Mailing Address - Country:US
Mailing Address - Phone:508-627-4539
Mailing Address - Fax:
Practice Address - Street 1:10 BENNETT WAY
Practice Address - Street 2:
Practice Address - City:EDGARTOWN
Practice Address - State:MA
Practice Address - Zip Code:02539
Practice Address - Country:US
Practice Address - Phone:508-627-4539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist