Individual
VICTORIA JEAN MABANTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OT
Contact information
Practice address
6011 E HANNA AVE STE M, INDIANAPOLIS, IN 46203-7115
(317) 787-3375
(317) 787-3376
Mailing address
1207 MORNINGSIDE DR, LEBANON, IN 46052-1963
(765) 482-6997
(317) 881-3421
Taxonomy
Speciality
Code
Description
License number
State
225XP0200X
Pediatric Occupational Therapist
Primary
31002307A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11643050
CAQH
—
Enumeration date
12/21/2006
Last updated
07/09/2007
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