Provider Demographics
NPI:1972669638
Name:BACON, VICTORIA LEE (EDD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:LEE
Last Name:BACON
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 KING PHILIP RD
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:MA
Mailing Address - Zip Code:02766-3021
Mailing Address - Country:US
Mailing Address - Phone:508-285-4622
Mailing Address - Fax:508-285-4622
Practice Address - Street 1:55 KING PHILIP RD
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:MA
Practice Address - Zip Code:02766-3021
Practice Address - Country:US
Practice Address - Phone:508-285-4622
Practice Address - Fax:508-285-4622
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6597103T00000X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05244Medicaid