Provider Demographics
NPI:1679396253
Name:EINEM, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:EINEM
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 1:51 CHRISTOPHER RD
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-2496
Mailing Address - Country:US
Mailing Address - Phone:818-523-2122
Mailing Address - Fax:
Practice Address - Street 1:2 CORPORATE BLVD NE STE 160
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2027
Practice Address - Country:US
Practice Address - Phone:404-228-8558
Practice Address - Fax:404-228-8659
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty