Provider Demographics
NPI:1881826915
Name:OTHON, VICTORIA M (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:M
Last Name:OTHON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-1188
Mailing Address - Country:US
Mailing Address - Phone:218-749-2881
Mailing Address - Fax:218-749-3806
Practice Address - Street 1:3203 W. 3RD AVE.
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746
Practice Address - Country:US
Practice Address - Phone:218-263-9237
Practice Address - Fax:218-262-3150
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN5602103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program