Provider Demographics
NPI:1750415881
Name:HORAZDOVSKY, PAMELA S (BSW, MAG)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
Last Name:HORAZDOVSKY
Suffix:
Gender:F
Credentials:BSW, MAG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60788 BEAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-9461
Mailing Address - Country:US
Mailing Address - Phone:907-299-0352
Mailing Address - Fax:907-235-4093
Practice Address - Street 1:60788 BEAR CREEK DR
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-9461
Practice Address - Country:US
Practice Address - Phone:907-299-0352
Practice Address - Fax:907-235-4093
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK312106171M00000X, 251B00000X, 385H00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No385H00000XRespite Care FacilityRespite Care
No172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG641Medicaid
AKHC1641Medicaid
AK312106OtherAK BUSINESS LICENSE NUMBE
AKCM79951Medicaid
AKCMG641Medicaid