Provider Demographics
NPI:1811729387
Name:PERREAULT, VICTORIA ROSE
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ROSE
Last Name:PERREAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3619
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95063-3619
Mailing Address - Country:US
Mailing Address - Phone:408-883-0586
Mailing Address - Fax:
Practice Address - Street 1:545 OCEAN VIEW AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-3363
Practice Address - Country:US
Practice Address - Phone:831-471-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT148249106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist