Healthcare Provider Details

I. General information

NPI: 1205952371
Provider Name (Legal Business Name): VICTOR ALBERTO WENGER REHABILITATION PROVI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5527 COROT CT
FAIRFAX VA
22032-3828
US

IV. Provider business mailing address

5527 COROT CT
FAIRFAX VA
22032-3828
US

V. Phone/Fax

Practice location:
  • Phone: 703-239-2442
  • Fax:
Mailing address:
  • Phone: 703-239-2442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number0715005211
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC35
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: