Provider Demographics
NPI:1962873653
Name:REAGAN, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:REAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2895 GREYSTONE LN
Mailing Address - Street 2:APARTMENT 8
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1149 W MONROE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-9736
Practice Address - Country:US
Practice Address - Phone:989-681-3852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101004968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist