Provider Demographics
NPI:1063119642
Name:PREWITT, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:PREWITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-538-4816
Mailing Address - Fax:
Practice Address - Street 1:701 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1612
Practice Address - Country:US
Practice Address - Phone:708-538-4816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171400000XOther Service ProvidersHealth & Wellness Coach
No251S00000XAgenciesCommunity/Behavioral Health