Healthcare Provider Details

I. General information

NPI: 1356337620
Provider Name (Legal Business Name): VICTOR CERRA EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 12TH ST SUITE 222
WHEELING WV
26003-3279
US

IV. Provider business mailing address

40 12TH ST SUITE 222
WHEELING WV
26003-3279
US

V. Phone/Fax

Practice location:
  • Phone: 304-232-0190
  • Fax: 304-232-4682
Mailing address:
  • Phone: 304-232-0190
  • Fax: 304-232-4682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number148
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: