Provider Demographics
NPI:1356728380
Name:WHITAKER, VICTORY
Entity type:Individual
Prefix:
First Name:VICTORY
Middle Name:
Last Name:WHITAKER
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 1:751 THIMBLE SHOALS BLVD
Mailing Address - Street 2:H-1
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3563
Mailing Address - Country:US
Mailing Address - Phone:757-295-1289
Mailing Address - Fax:
Practice Address - Street 1:751 THIMBLE SHOALS BLVD
Practice Address - Street 2:H-1
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3563
Practice Address - Country:US
Practice Address - Phone:757-295-1289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2830251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health