Provider Demographics
NPI:1972147056
Name:GRAYSON-BALTIMORE, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:GRAYSON-BALTIMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 46TH ST
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08110-3668
Mailing Address - Country:US
Mailing Address - Phone:856-304-4677
Mailing Address - Fax:
Practice Address - Street 1:1656 KAIGHN AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3607
Practice Address - Country:US
Practice Address - Phone:856-304-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101YM0800X
104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ843558230Medicaid