Provider Demographics
NPI:1982466892
Name:SMITH, VICTORIA B
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:B
Last Name:SMITH
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 1:422 S NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-5616
Mailing Address - Country:US
Mailing Address - Phone:708-628-0577
Mailing Address - Fax:
Practice Address - Street 1:600 HOLIDAY PLAZA DR
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2241
Practice Address - Country:US
Practice Address - Phone:708-628-0577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician