Provider Demographics
NPI:1063724938
Name:HEAD, VICTORIA SUE (COTA)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:SUE
Last Name:HEAD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MS
Other - First Name:VICTORIA
Other - Middle Name:SUE
Other - Last Name:HOOGLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:445 GRANDVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:ADELL
Mailing Address - State:WI
Mailing Address - Zip Code:53001-1164
Mailing Address - Country:US
Mailing Address - Phone:920-254-7209
Mailing Address - Fax:
Practice Address - Street 1:3014 ERIE AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3658
Practice Address - Country:US
Practice Address - Phone:920-459-3028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI430 - 027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant