Provider Demographics
NPI:1174120786
Name:HEUTMAKER, VICTORIA (CB61101411)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:HEUTMAKER
Suffix:
Gender:F
Credentials:CB61101411
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W 7TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2833
Mailing Address - Country:US
Mailing Address - Phone:509-850-1080
Mailing Address - Fax:
Practice Address - Street 1:707 W 7TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2833
Practice Address - Country:US
Practice Address - Phone:509-850-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61101411106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician