Basic Information
| Provider Information | |||||||||
| NPI: | 1386130292 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALICIA A VICTORY, PSYD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5777 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378025777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652462104 | ||||||||
| FaxNumber: | 8652462106 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 WALNUT LN | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156252117 | ||||||||
| FaxNumber: | 8652462104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2018 | ||||||||
| LastUpdateDate: | 09/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | VICTORY | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6156252117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3279 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.