Provider Demographics
NPI:1992305064
Name:DE MACENA MARQUES, VICTORIA ADRIANO (MSCP)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ADRIANO
Last Name:DE MACENA MARQUES
Suffix:
Gender:F
Credentials:MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 SAINT CLAIR DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-3936
Mailing Address - Country:US
Mailing Address - Phone:248-720-8975
Mailing Address - Fax:
Practice Address - Street 1:5665 W MAPLE RD STE A
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3741
Practice Address - Country:US
Practice Address - Phone:248-805-1879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362008438103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical