Provider Demographics
NPI:1063041242
Name:LONG, VICTORIA (CPM, LM)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 COUNTY ROAD 203
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-6289
Mailing Address - Country:US
Mailing Address - Phone:512-755-2308
Mailing Address - Fax:
Practice Address - Street 1:1840 COUNTY ROAD 203
Practice Address - Street 2:
Practice Address - City:BURNET
Practice Address - State:TX
Practice Address - Zip Code:78611-6289
Practice Address - Country:US
Practice Address - Phone:512-755-2308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20030004176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife