Provider Demographics
NPI:1629637962
Name:IP, VICTOR
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:IP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7375 WOODWARD AVE STE 2800
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3157
Mailing Address - Country:US
Mailing Address - Phone:313-710-8744
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:7375 WOODWARD AVE STE 2800
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3157
Practice Address - Country:US
Practice Address - Phone:313-710-8744
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010047103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical