Provider Demographics
NPI:1407908833
Name:THEROUX, VICKY LYNN (OTR L)
Entity Type:Individual
Prefix:MS
First Name:VICKY
Middle Name:LYNN
Last Name:THEROUX
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:RT 1 BOX 285 GLADDEN ST
Mailing Address - Street 2:
Mailing Address - City:WESTERN GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72685
Mailing Address - Country:US
Mailing Address - Phone:870-688-7348
Mailing Address - Fax:
Practice Address - Street 1:18 COUNTY ROAD 458
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-8212
Practice Address - Country:US
Practice Address - Phone:870-425-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1902225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist