Provider Demographics
NPI:1124622485
Name:BOETTGER, VICTORIA (MOT)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:
Last Name:BOETTGER
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:MS
Other - First Name:VICTORIA
Other - Middle Name:GABRIELLA
Other - Last Name:WYMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27212 N 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-7329
Mailing Address - Country:US
Mailing Address - Phone:480-939-4097
Mailing Address - Fax:
Practice Address - Street 1:2302 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-1201
Practice Address - Country:US
Practice Address - Phone:623-242-6908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTLL-000028225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTLL-000028OtherARIZONA BOARD OF OCCUPATIONAL THERAPY EXAMINERS