Healthcare Provider Details

I. General information

NPI: 1437079209
Provider Name (Legal Business Name): REA VICTORY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 DEL PRADO BLVD S STE 300-1041
CAPE CORAL FL
33990-6739
US

IV. Provider business mailing address

7860 W COMMERCIAL BLVD SUITE 200 #599
LAUDERHILL FL
33351
US

V. Phone/Fax

Practice location:
  • Phone: 904-601-5463
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number29430
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: