Provider Demographics
NPI:1649848136
Name:LICHTENBERG, VIKTORIYA
Entity type:Individual
Prefix:
First Name:VIKTORIYA
Middle Name:
Last Name:LICHTENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIKTORIYA
Other - Middle Name:
Other - Last Name:PETRUCHENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:369 S HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1325
Mailing Address - Country:US
Mailing Address - Phone:208-390-2305
Mailing Address - Fax:
Practice Address - Street 1:369 S HOLMES AVE
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1325
Practice Address - Country:US
Practice Address - Phone:208-390-2305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0002196996Medicaid