Provider Demographics
NPI:1104028190
Name:HAIRSTON, PAMELA C (DPT)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:C
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14021 REVEREND BOUCHER PL
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-5959
Mailing Address - Country:US
Mailing Address - Phone:301-627-1823
Mailing Address - Fax:
Practice Address - Street 1:14021 REVEREND BOUCHER PL
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-5959
Practice Address - Country:US
Practice Address - Phone:301-627-1823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-03
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist