Provider Demographics
NPI:1376669705
Name:BRODEUR, PAMELA GAYLE (COTA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:GAYLE
Last Name:BRODEUR
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ZEOLITE PL
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5229
Mailing Address - Country:US
Mailing Address - Phone:386-206-4834
Mailing Address - Fax:
Practice Address - Street 1:350 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-7028
Practice Address - Country:US
Practice Address - Phone:386-677-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 8752224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant