Provider Demographics
NPI:1821406844
Name:SMITH, VICTORIA J (LMT, CST)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT, CST
Other - Prefix:
Other - First Name:VICKY
Other - Middle Name:JO
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT, CST
Mailing Address - Street 1:1207 8TH ST E
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-4244
Mailing Address - Country:US
Mailing Address - Phone:406-883-8197
Mailing Address - Fax:406-883-8697
Practice Address - Street 1:1207 8TH ST E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-4244
Practice Address - Country:US
Practice Address - Phone:406-883-8197
Practice Address - Fax:406-883-8697
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT388225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist