Provider Demographics
NPI:1023000940
Name:FREDERICO, VICTORIA D (OTR/L)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:D
Last Name:FREDERICO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31926 VIA ARARAT DR
Mailing Address - Street 2:
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-4340
Mailing Address - Country:US
Mailing Address - Phone:585-683-0408
Mailing Address - Fax:
Practice Address - Street 1:31926 VIA ARARAT DR
Practice Address - Street 2:
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-4340
Practice Address - Country:US
Practice Address - Phone:585-683-0408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04615225X00000X
CA15499225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP79886Medicare UPIN