Healthcare Provider Details

I. General information

NPI: 1881826915
Provider Name (Legal Business Name): VICTORIA M. OTHON PSY.D, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 W. 3RD AVE.
HIBBING MN
55746
US

IV. Provider business mailing address

PO BOX 1188
VIRGINIA MN
55792-1188
US

V. Phone/Fax

Practice location:
  • Phone: 218-263-9237
  • Fax: 218-262-3150
Mailing address:
  • Phone: 218-749-2881
  • Fax: 218-749-3806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5602
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: