Provider Demographics
NPI:1992311294
Name:GREENWELL, VICTORIA LAUREN (EDS, NCSP)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LAUREN
Last Name:GREENWELL
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 TWISTED OAK DR NW
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-1124
Mailing Address - Country:US
Mailing Address - Phone:859-333-1841
Mailing Address - Fax:
Practice Address - Street 1:40 DOUGLAS AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-4611
Practice Address - Country:US
Practice Address - Phone:540-853-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813001110103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool