1033484449 NPI number — MISS VICTORIA ANN LISTON BSW, CADC

Table of content: MISS VICTORIA ANN LISTON BSW, CADC (NPI 1033484449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033484449 NPI number — MISS VICTORIA ANN LISTON BSW, CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LISTON
Provider First Name:
VICTORIA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
BSW, CADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033484449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2148 VADALABENE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62062-5632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-288-3100
Provider Business Mailing Address Fax Number:
618-288-3371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2148 VADALABENE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62062-5632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-288-3100
Provider Business Practice Location Address Fax Number:
618-288-3371
Provider Enumeration Date:
03/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  150.013697 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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