Provider Demographics
NPI:1063734663
Name:FRYE, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:FRYE
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 1:5354 PARKDALE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1617
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:
Practice Address - Street 1:900 LONG LAKE RD STE 160
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-6414
Practice Address - Country:US
Practice Address - Phone:612-706-9630
Practice Address - Fax:612-706-9617
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN408101YP2500X
MN101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1063734663Medicaid