Provider Demographics
NPI:1760750517
Name:RUSSELL, PAMELA GERARD (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:GERARD
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:PAMELA
Other - Middle Name:JEAN
Other - Last Name:GERARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:12022 MORTONS CORNERS RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-9737
Mailing Address - Country:US
Mailing Address - Phone:716-592-5451
Mailing Address - Fax:
Practice Address - Street 1:11720 PARTRIDGE RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:NY
Practice Address - Zip Code:14080-9800
Practice Address - Country:US
Practice Address - Phone:716-537-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003037-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist