Provider Demographics
NPI:1326263997
Name:WYCKOFF, PAMELA MOORE (OT)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:MOORE
Last Name:WYCKOFF
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 1:10 SPANGENBURG AVENUE
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-2724
Mailing Address - Country:US
Mailing Address - Phone:570-977-3691
Mailing Address - Fax:570-424-5664
Practice Address - Street 1:1233 N. 9TH STREET
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-1172
Practice Address - Country:US
Practice Address - Phone:570-872-9222
Practice Address - Fax:570-424-5664
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC003029L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017878950001Medicaid