Provider Demographics
NPI:1467439448
Name:HENRY, PAMELA L (OT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:L
Last Name:HENRY
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 1:1800 HOLLISTER DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5263
Mailing Address - Country:US
Mailing Address - Phone:847-918-7947
Mailing Address - Fax:847-918-9622
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:SUITE 205
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5263
Practice Address - Country:US
Practice Address - Phone:847-918-7947
Practice Address - Fax:847-918-9622
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3811-026225X00000X
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40844900Medicaid