Provider Demographics
NPI:1114389756
Name:WHITAKER, PAMELA (OT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5013
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-0019
Mailing Address - Country:US
Mailing Address - Phone:770-584-0081
Mailing Address - Fax:
Practice Address - Street 1:9620 HIGHWAY 109
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:GA
Practice Address - Zip Code:30295-3445
Practice Address - Country:US
Practice Address - Phone:770-584-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002179225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist