Provider Demographics
NPI:1194006080
Name:CLEVENGER, PAMELA JEAN (MS,OTRL)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:CLEVENGER
Suffix:
Gender:F
Credentials:MS,OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4065 SALADIN DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6249
Mailing Address - Country:US
Mailing Address - Phone:616-942-2081
Mailing Address - Fax:616-942-5932
Practice Address - Street 1:4065 SALADIN DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6249
Practice Address - Country:US
Practice Address - Phone:616-942-2081
Practice Address - Fax:616-942-5932
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008023225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist