Provider Demographics
NPI:1316460033
Name:VICTORIA, LUIS RAFAEL
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:RAFAEL
Last Name:VICTORIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 HUNTER ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-4444
Mailing Address - Country:US
Mailing Address - Phone:561-672-4973
Mailing Address - Fax:
Practice Address - Street 1:521 HUNTER ST
Practice Address - Street 2:APT 1
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405
Practice Address - Country:US
Practice Address - Phone:561-672-4973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty