Provider Demographics
NPI:1154743367
Name:ELLINGTON-DEITZ, VICTORIA (LPC-IT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:ELLINGTON-DEITZ
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:M
Other - Last Name:ELLINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2002 ATWOOD AVE
Mailing Address - Street 2:SUITE 217
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5368
Mailing Address - Country:US
Mailing Address - Phone:608-244-4859
Mailing Address - Fax:
Practice Address - Street 1:2002 ATWOOD AVE
Practice Address - Street 2:SUITE 217
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5368
Practice Address - Country:US
Practice Address - Phone:608-244-4859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1999-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health