Provider Demographics
NPI:1861976953
Name:VICTOR, TRISTIN L
Entity type:Individual
Prefix:
First Name:TRISTIN
Middle Name:L
Last Name:VICTOR
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 4752
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0197
Mailing Address - Country:US
Mailing Address - Phone:541-500-8655
Mailing Address - Fax:800-433-1396
Practice Address - Street 1:233 4TH ST STE 5
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2043
Practice Address - Country:US
Practice Address - Phone:541-241-8925
Practice Address - Fax:800-433-1396
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health