Basic Information
| Provider Information | |||||||||
| NPI: | 1538767140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EGGEBRECHT | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14145 SIMONE DR | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483153228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865666280 | ||||||||
| FaxNumber: | 5865661898 | ||||||||
| Practice Location | |||||||||
| Address1: | 14145 SIMONE DR | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483153228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865666280 | ||||||||
| FaxNumber: | 5865661898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2020 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7101007206 | MI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.