Provider Demographics
NPI:1295909026
Name:WILBURN, VICTORIA (OTR)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:WILBURN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7739 E 88TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1231
Mailing Address - Country:US
Mailing Address - Phone:317-578-0410
Mailing Address - Fax:317-578-0520
Practice Address - Street 1:7739 E 88TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1231
Practice Address - Country:US
Practice Address - Phone:317-578-0410
Practice Address - Fax:317-578-0520
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004153A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200685160Medicaid