Provider Demographics
NPI:1154495919
Name:BOTHMAN, VICTORIA LEA (LMT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEA
Last Name:BOTHMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1441
Mailing Address - Country:US
Mailing Address - Phone:618-791-8742
Mailing Address - Fax:
Practice Address - Street 1:7902 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2704
Practice Address - Country:US
Practice Address - Phone:618-791-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002002533225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist