Provider Demographics
NPI:1376134809
Name:MANDERS, PAMELA M
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:MANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 HACKENSACK AVE # 2
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-5875
Mailing Address - Country:US
Mailing Address - Phone:954-240-4836
Mailing Address - Fax:
Practice Address - Street 1:86 HACKENSACK AVE # 2
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-5875
Practice Address - Country:US
Practice Address - Phone:954-240-4836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01230200225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist