MEDICARE: VICTORY COUNSELING SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801088738	MI

General Provider Information

NPI Number	:	1053646968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	185 E MAIN ST
Second Line	:	STE 402
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-4431
Country	:	US
Telephone Number	:	269-925-8222
Fax Number	:	269-925-8354

Provider Business Practice Location Address
First Line	:	185 E MAIN ST
Second Line	:	STE 402
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-4431
Country	:	US
Telephone Number	:	269-925-8222
Fax Number	:	269-925-8354

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	MRS. VONETTA RESHAN MCGINNIS
Credential	:	LMSW
Telephone Number	:	269-925-8222

Provider Enumeration Date	:	10/09/2009
Last Update Date	:	02/15/2012

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