Provider Demographics
NPI:1467597153
Name:MACON, PAMELA MICHELLE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:MICHELLE
Last Name:MACON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 IRENE CT
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-4141
Mailing Address - Country:US
Mailing Address - Phone:314-568-7822
Mailing Address - Fax:
Practice Address - Street 1:11365 DORSETT RD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-3411
Practice Address - Country:US
Practice Address - Phone:314-872-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1126342251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics