Provider Demographics
NPI:1568123883
Name:DAZA, VICTORIA
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:
Last Name:DAZA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3502
Mailing Address - Country:US
Mailing Address - Phone:718-327-7002
Mailing Address - Fax:
Practice Address - Street 1:15610 BAISLEY BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-2821
Practice Address - Country:US
Practice Address - Phone:929-420-1893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-08
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
221700000X
NY003085221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist