Provider Demographics
NPI:1851477095
Name:PERCIVAL, PAMELA V (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:V
Last Name:PERCIVAL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 EAST GENESSEE STREET
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214
Mailing Address - Country:US
Mailing Address - Phone:315-475-2215
Mailing Address - Fax:
Practice Address - Street 1:2100 EAST GENESSEE STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214
Practice Address - Country:US
Practice Address - Phone:315-475-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007381103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00751217Medicaid
SO73811OtherWORKERS COMP
SO73811OtherWORKERS COMP