Basic Information
| Provider Information | |||||||||
| NPI: | 1548659618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTORIA SEPULVEDA, PHD, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BECKER-GIBEAU PSYCHOLOGICAL SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623772006 | ||||||||
| FaxNumber: | 2623775552 | ||||||||
| Practice Location | |||||||||
| Address1: | 14135 N CEDARBURG RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530971416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623772006 | ||||||||
| FaxNumber: | 2623775552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2015 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEPULVEDA | ||||||||
| AuthorizedOfficialFirstName: | VICTORIA | ||||||||
| AuthorizedOfficialMiddleName: | IRENE MILLER | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 4193775836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D., LPC, CSAC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 5482-125 | WI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 15861-132 | WI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 5482-125 | WI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.