Provider Demographics
NPI:1962120865
Name:HARRELSON, VICTORIA VASTI (RBT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:VASTI
Last Name:HARRELSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11681 VOYAGER PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3864
Mailing Address - Country:US
Mailing Address - Phone:719-344-9342
Mailing Address - Fax:
Practice Address - Street 1:11681 VOYAGER PKWY STE 150
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-3864
Practice Address - Country:US
Practice Address - Phone:719-344-9342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-22-227248103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORBT-22-227248Medicaid