Provider Demographics
NPI:1396296414
Name:ROSS-HOUSTON, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:ROSS-HOUSTON
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 40249
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-0249
Mailing Address - Country:US
Mailing Address - Phone:817-938-3277
Mailing Address - Fax:
Practice Address - Street 1:7312 SAVOY DR
Practice Address - Street 2:APT.813
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-6551
Practice Address - Country:US
Practice Address - Phone:817-938-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000000Medicaid
TX000000Medicaid