Provider Demographics
NPI:1265919591
Name:SHOGREN, VICTORIA GRACE (DPT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:GRACE
Last Name:SHOGREN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3652
Mailing Address - Country:US
Mailing Address - Phone:443-512-8337
Mailing Address - Fax:
Practice Address - Street 1:100 WALTER WARD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-1285
Practice Address - Country:US
Practice Address - Phone:443-512-8337
Practice Address - Fax:443-327-5282
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0014503225100000X
PAPT026807225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA779501OtherMEDICARE
PA1035150340028Medicaid