Basic Information
| Provider Information | |||||||||
| NPI: | 1063724938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEAD | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOOGLAND | ||||||||
| OtherFirstName: | VICTORIA | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 445 GRANDVIEW CIR | ||||||||
| Address2: | |||||||||
| City: | ADELL | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530011164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202547209 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3014 ERIE AVE | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530813658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204593028 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 430 - 027 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.