Provider Demographics
NPI:1902120629
Name:VICTORY, MARISA HELENA (PSYD, MA, MSW)
Entity Type:Individual
Prefix:MISS
First Name:MARISA
Middle Name:HELENA
Last Name:VICTORY
Suffix:
Gender:F
Credentials:PSYD, MA, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 LOCHVALE PEAK CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-2183
Mailing Address - Country:US
Mailing Address - Phone:614-204-5602
Mailing Address - Fax:
Practice Address - Street 1:2100 N MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1877
Practice Address - Country:US
Practice Address - Phone:745-461-9005
Practice Address - Fax:574-546-1999
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39154103TC0700X
OHS.09011211041C0700X
OHI.12012351041C0700X
IN20043650B103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP.085240OtherSTATE LICENSE