Provider Demographics
NPI:1427347244
Name:CANARY, VICTORIA IONE (MPT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:IONE
Last Name:CANARY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-1439
Mailing Address - Country:US
Mailing Address - Phone:732-431-2155
Mailing Address - Fax:732-707-3920
Practice Address - Street 1:900 NORTHROP RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1997
Practice Address - Country:US
Practice Address - Phone:203-949-1534
Practice Address - Fax:203-949-9036
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01649000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist