Provider Demographics
NPI:1750863718
Name:ANDERSON, VICTORIA LYNN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 OAKRIDGE AVE APT 2218
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-1863
Mailing Address - Country:US
Mailing Address - Phone:304-479-3102
Mailing Address - Fax:
Practice Address - Street 1:510 S 1ST ST
Practice Address - Street 2:
Practice Address - City:BROWNFIELD
Practice Address - State:TX
Practice Address - Zip Code:79316-5544
Practice Address - Country:US
Practice Address - Phone:806-673-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214340224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant