Provider Demographics
NPI:1770173254
Name:PETERSON, VICTORIA (OTR/L)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:GOERL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:748 S E ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1733
Mailing Address - Country:US
Mailing Address - Phone:308-383-9573
Mailing Address - Fax:
Practice Address - Street 1:700 S J ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1623
Practice Address - Country:US
Practice Address - Phone:541-947-2114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR445767225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist