Provider Demographics
NPI:1760526180
Name:DEITER-SANDS, PAMELA JOYCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:JOYCE
Last Name:DEITER-SANDS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:JOYCE
Other - Last Name:DEITER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:78 EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4325
Mailing Address - Country:US
Mailing Address - Phone:860-633-7882
Mailing Address - Fax:
Practice Address - Street 1:78 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4325
Practice Address - Country:US
Practice Address - Phone:860-633-7882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2005103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
680001142Medicare ID - Type Unspecified