Healthcare Provider Details

I. General information

NPI: 1720816432
Provider Name (Legal Business Name): VICTORY BAY MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8445 KEYSTONE XING STE 180
INDIANAPOLIS IN
46240-0020
US

IV. Provider business mailing address

7 EVES DR STE 100
MARLTON NJ
08053-3196
US

V. Phone/Fax

Practice location:
  • Phone: 856-454-3104
  • Fax:
Mailing address:
  • Phone: 856-282-5590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MELLON
Title or Position: DIRECTOR OF REGULATORY COMPLIANCE &
Credential:
Phone: 856-282-5590