Provider Demographics
NPI:1467171074
Name:RICHARDS, VICTORIA CLAIRE (COTA/L)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:CLAIRE
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 MINER LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3444
Mailing Address - Country:US
Mailing Address - Phone:309-252-1179
Mailing Address - Fax:
Practice Address - Street 1:1200 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3428
Practice Address - Country:US
Practice Address - Phone:309-833-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003263224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty