Provider Demographics
NPI:1053717801
Name:VICTOR, AUDREY E (MA, ATC, LAT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:E
Last Name:VICTOR
Suffix:
Gender:F
Credentials:MA, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 STONE HOLLOW DR APT 510
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-6093
Mailing Address - Country:US
Mailing Address - Phone:979-551-1919
Mailing Address - Fax:
Practice Address - Street 1:525 A H EHRIG DR
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-2428
Practice Address - Country:US
Practice Address - Phone:979-277-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT58442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer