Healthcare Provider Details

I. General information

NPI: 1588267389
Provider Name (Legal Business Name): VICTORIA LYNN SANSOM MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 W NORTH SHORE AVE APT 2F
CHICAGO IL
60626-4619
US

IV. Provider business mailing address

1057 W NORTH SHORE AVE APT 2F
CHICAGO IL
60626-4619
US

V. Phone/Fax

Practice location:
  • Phone: 972-989-6728
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056016619
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number117459
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: