Provider Demographics
NPI:1457475378
Name:VICKERMAN, SUSAN LOUISE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LOUISE
Last Name:VICKERMAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:LOUISE
Other - Last Name:VANMOER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2263 623RD AVE
Mailing Address - Street 2:
Mailing Address - City:ALBIA
Mailing Address - State:IA
Mailing Address - Zip Code:52531-8660
Mailing Address - Country:US
Mailing Address - Phone:641-932-1673
Mailing Address - Fax:641-932-1708
Practice Address - Street 1:2263 623RD AVE
Practice Address - Street 2:
Practice Address - City:ALBIA
Practice Address - State:IA
Practice Address - Zip Code:52531-8660
Practice Address - Country:US
Practice Address - Phone:641-932-1673
Practice Address - Fax:641-932-1708
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01389225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist