Provider Demographics
NPI:1578660155
Name:WILSON, PAMELA (OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 EASTERN BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1208
Mailing Address - Country:US
Mailing Address - Phone:860-527-7161
Mailing Address - Fax:860-652-8411
Practice Address - Street 1:195 EASTERN BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-1208
Practice Address - Country:US
Practice Address - Phone:860-527-7161
Practice Address - Fax:860-652-8411
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000684225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
670000058Medicare ID - Type Unspecified