Provider Demographics
NPI:1275810327
Name:PETRUSHESKY, PAMELA KONSTANTINA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:KONSTANTINA
Last Name:PETRUSHESKY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 RUNNING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-3309
Mailing Address - Country:US
Mailing Address - Phone:716-668-5756
Mailing Address - Fax:
Practice Address - Street 1:2486 MAIN RD
Practice Address - Street 2:
Practice Address - City:EAST PEMBROKE
Practice Address - State:NY
Practice Address - Zip Code:14056
Practice Address - Country:US
Practice Address - Phone:585-599-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005729-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist