Healthcare Provider Details

I. General information

NPI: 1629581129
Provider Name (Legal Business Name): VICTORIA IVENS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA OLDANI DPT

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 GLENDA TRCE STE C
NEWNAN GA
30265-3868
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 470-683-4640
  • Fax: 470-683-4639
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015181
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: