Provider Demographics
NPI:1619231719
Name:ANDERSON, VICTORIA JEANNINE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:JEANNINE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:VICTORIA
Other - Middle Name:JEANNINE
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:530 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-2598
Mailing Address - Country:US
Mailing Address - Phone:815-876-4494
Mailing Address - Fax:815-876-2030
Practice Address - Street 1:530 PARK AVE E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2598
Practice Address - Country:US
Practice Address - Phone:815-876-4494
Practice Address - Fax:815-876-2030
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001338225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant