Healthcare Provider Details

I. General information

NPI: 1861022204
Provider Name (Legal Business Name): VICTORIA YACKEVICZ MA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8003 SILVER GRV
SAN ANTONIO TX
78254-5732
US

IV. Provider business mailing address

8003 SILVER GRV
SAN ANTONIO TX
78254-5732
US

V. Phone/Fax

Practice location:
  • Phone: 210-380-5364
  • Fax:
Mailing address:
  • Phone: 210-380-5364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number73177
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: