Provider Demographics
NPI:1265596241
Name:MABANTA, VICTORIA JEAN (OT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:JEAN
Last Name:MABANTA
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:JEAN
Other - Last Name:DELANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1207 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1963
Mailing Address - Country:US
Mailing Address - Phone:765-482-6997
Mailing Address - Fax:317-881-3421
Practice Address - Street 1:6011 E HANNA AVE STE M
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-7115
Practice Address - Country:US
Practice Address - Phone:317-787-3375
Practice Address - Fax:317-787-3376
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002307A225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
11643050OtherCAQH