Provider Demographics
NPI:1760037808
Name:DISSANAYAKE, PAMUDU (OTR/L)
Entity Type:Individual
Prefix:
First Name:PAMUDU
Middle Name:
Last Name:DISSANAYAKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33278 TALL OAKS CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-4548
Mailing Address - Country:US
Mailing Address - Phone:248-787-2973
Mailing Address - Fax:
Practice Address - Street 1:700 STEWART RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-5304
Practice Address - Country:US
Practice Address - Phone:734-240-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010529225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist