Provider Demographics
NPI:1205104957
Name:CRECCA, PAMELA MICHELLE (SLP)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:MICHELLE
Last Name:CRECCA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:MICHELLE
Other - Last Name:CRECCA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22555-0542
Mailing Address - Country:US
Mailing Address - Phone:252-571-1419
Mailing Address - Fax:
Practice Address - Street 1:1936 OPITZ BLVD STE A
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3360
Practice Address - Country:US
Practice Address - Phone:703-543-9164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4744235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411490Medicaid