Provider Demographics
NPI:1518658913
Name:DESIRA, VICTORIA THERESA (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:VICTORIA
Middle Name:THERESA
Last Name:DESIRA
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 1:1390 E CHESTERFIELD ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2610
Mailing Address - Country:US
Mailing Address - Phone:517-896-3471
Mailing Address - Fax:
Practice Address - Street 1:1390 E CHESTERFIELD ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2610
Practice Address - Country:US
Practice Address - Phone:517-896-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201013395225XN1300X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation