Provider Demographics
NPI:1962148700
Name:VIVODA, VICKY LYNN (COTA/L)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:LYNN
Last Name:VIVODA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 RIDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3360
Mailing Address - Country:US
Mailing Address - Phone:720-505-1865
Mailing Address - Fax:
Practice Address - Street 1:2622 RIDGEWOOD LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-3360
Practice Address - Country:US
Practice Address - Phone:720-505-1865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001495224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant