Provider Demographics
NPI:1962907949
Name:LOFGREN, VICTORIA JEAN-MAXIN
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:JEAN-MAXIN
Last Name:LOFGREN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:VICTORIA
Other - Middle Name:JEAN
Other - Last Name:MAXIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24715 LITTLE MACK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3207
Mailing Address - Country:US
Mailing Address - Phone:586-777-0942
Mailing Address - Fax:
Practice Address - Street 1:24715 LITTLE MACK AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3207
Practice Address - Country:US
Practice Address - Phone:586-777-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
MI6451017782101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional