Provider Demographics
NPI:1700025475
Name:LONG, PAMELA (OT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:LONG
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:PO BOX 203
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-0203
Mailing Address - Country:US
Mailing Address - Phone:314-877-8754
Mailing Address - Fax:
Practice Address - Street 1:12 SAFFRIN HILL CT
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1561
Practice Address - Country:US
Practice Address - Phone:314-877-8754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X, 225XN1300X, 225XP0019X
TX113413225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics