Provider Demographics
NPI:1730661265
Name:ST.MIRE, VICTORIA D (COTA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:D
Last Name:ST.MIRE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 CUMMINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-4008
Mailing Address - Country:US
Mailing Address - Phone:856-227-0036
Mailing Address - Fax:
Practice Address - Street 1:410 E MACPHAIL RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4410
Practice Address - Country:US
Practice Address - Phone:410-879-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP009390224Z00000X
NJ46TA09100700224Z00000X
MDA02627224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant