Healthcare Provider Details

I. General information

NPI: 1396113593
Provider Name (Legal Business Name): VICTORIA MARIE GOTTFRIED LCSW, LISW, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 MADISON AVE
COVINGTON KY
41011-1562
US

IV. Provider business mailing address

502 FARRELL DR
COVINGTON KY
41011-3717
US

V. Phone/Fax

Practice location:
  • Phone: 859-331-3292
  • Fax: 859-578-2864
Mailing address:
  • Phone: 859-578-3204
  • Fax: 859-578-3273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3929
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1500401
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: