Basic Information
| Provider Information | |||||||||
| NPI: | 1124781364 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTORY PSYCH CONSULTATION SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10 ETON DR | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082478768 | ||||||||
| FaxNumber: | 6464908780 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 ETON DR | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082478768 | ||||||||
| FaxNumber: | 6464908780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2021 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANIMASHAUN | ||||||||
| AuthorizedOfficialFirstName: | YAHAYA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTIONER | ||||||||
| AuthorizedOfficialTelephone: | 9082478768 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | APN | ||||||||
| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.