Provider Demographics
NPI:1215411939
Name:PEMBERTON, TIMOTHY WAYNE (OT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:PEMBERTON
Suffix:
Gender:M
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 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-286-1669
Mailing Address - Fax:314-747-3662
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DEPT OCCUPATIONAL THERAPY, STE 6F
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-286-1669
Practice Address - Fax:314-747-3662
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018009363225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO470064153Medicaid