Provider Demographics
NPI:1376806968
Name:DAUGHERTY, PAMELA KIRAN (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:KIRAN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3529 SALENA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-4024
Mailing Address - Country:US
Mailing Address - Phone:314-477-5223
Mailing Address - Fax:
Practice Address - Street 1:10176 CORPORATE SQUARE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-2924
Practice Address - Country:US
Practice Address - Phone:314-432-6200
Practice Address - Fax:314-849-2721
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010005293224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant