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General NPI Number Information
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NPI Number | 1942698246
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Entity Type | Organization
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Legal Business Name | VICTORY MOUNTAIN PSYCHOTHERAPY, INC
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Dates
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Enumeration Date | 01/08/2015
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 27659 BURGUNDY CROSSING LANE
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City | CANYON COUNTRY
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State | CA
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Zip | 91351
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Country | US
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Telephone | 540-842-4999
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Fax | 540-371-8428
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Provider Business Mailing Address
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Address Line | 18565 SOLEDAD CANYON ROAD BOX 302
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City | CANYON COUNTRY
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State | CA
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Zip | 91351-3700
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Country | US
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Telephone | 540-842-4999
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Fax | 540-371-8428
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Authorized Official
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Title or Position | CEO/OWNER
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Name | MR. JEFFREY SUMPOLEC
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Credential | LPCC
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Telephone | 540-842-4999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0701003590
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License Number State | VA
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