Provider Demographics
NPI:1619334083
Name:IVANOV, VIKTORIA (PTA)
Entity Type:Individual
Prefix:
First Name:VIKTORIA
Middle Name:
Last Name:IVANOV
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14245 DICKENS ST
Mailing Address - Street 2:UNIT 104
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14245 DICKENS ST
Practice Address - Street 2:UNIT 104
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-4113
Practice Address - Country:US
Practice Address - Phone:310-502-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10443225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant