Provider Demographics
NPI:1295858686
Name:DESANTIS, PAMELA SUE (MOTRL)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:SUE
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEW STANTON
Mailing Address - State:PA
Mailing Address - Zip Code:15672-9795
Mailing Address - Country:US
Mailing Address - Phone:412-953-7717
Mailing Address - Fax:
Practice Address - Street 1:2904 SEMINARY DR
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-3700
Practice Address - Country:US
Practice Address - Phone:724-832-8272
Practice Address - Fax:724-837-8278
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC005974L225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01889355Medicaid