Provider Demographics
NPI:1407999832
Name:MAGNAN, VICTORIA J (OTR)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:J
Last Name:MAGNAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:J
Other - Last Name:ENGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:145 RIVERLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4013
Mailing Address - Country:US
Mailing Address - Phone:920-285-2953
Mailing Address - Fax:
Practice Address - Street 1:145 RIVERLAWN AVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4013
Practice Address - Country:US
Practice Address - Phone:920-285-2953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2435225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI2143001OtherMEDICARE PTAN
WI1407999832OtherMEDICARE NPI