Provider Demographics
NPI:1003120551
Name:VICTORIA, ETHEL-GRACE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ETHEL-GRACE
Middle Name:
Last Name:VICTORIA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:VICTORIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1226 ELM LAKE CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-3900
Mailing Address - Country:US
Mailing Address - Phone:408-313-0175
Mailing Address - Fax:
Practice Address - Street 1:1150 TILTON DR
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-2440
Practice Address - Country:US
Practice Address - Phone:916-300-7854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4017225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation