Provider Demographics
NPI:1720290679
Name:CAVALLO, PAMELA A (MED, DT)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:A
Last Name:CAVALLO
Suffix:
Gender:F
Credentials:MED, DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558
Mailing Address - Country:US
Mailing Address - Phone:708-784-1504
Mailing Address - Fax:
Practice Address - Street 1:4045 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558
Practice Address - Country:US
Practice Address - Phone:708-784-1504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist