Healthcare Provider Details

I. General information

NPI: 1992640627
Provider Name (Legal Business Name): VICTORIA DOUGLAS CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 GOLD RIDGE TRL
POLLOCK PINES CA
95726-9734
US

IV. Provider business mailing address

3670 GOLD RIDGE TRL
POLLOCK PINES CA
95726-9734
US

V. Phone/Fax

Practice location:
  • Phone: 530-391-9095
  • Fax:
Mailing address:
  • Phone: 530-391-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number102220
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: