Provider Demographics
NPI:1588401558
Name:THOMAS, VICTORIA ANQUINETTE (BT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANQUINETTE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11755 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1015
Mailing Address - Country:US
Mailing Address - Phone:708-586-4239
Mailing Address - Fax:
Practice Address - Street 1:11755 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1015
Practice Address - Country:US
Practice Address - Phone:708-586-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBACB815174106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician