Provider Demographics
NPI:1841562634
Name:MIST, PAMELA WELLINGTON (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:WELLINGTON
Last Name:MIST
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32521 MOUNT HERMON RD
Mailing Address - Street 2:
Mailing Address - City:PARSONSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21849-2064
Mailing Address - Country:US
Mailing Address - Phone:443-366-4499
Mailing Address - Fax:443-736-7480
Practice Address - Street 1:3000 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3311
Practice Address - Country:US
Practice Address - Phone:443-366-4499
Practice Address - Fax:443-736-7480
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00490224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA00490OtherMARYLAND BOARD OF OCCUPATIONAL THERAPY