Provider Demographics
NPI:1194119735
Name:CARROLL, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CARROLL
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 1:71 BRUNELL RD
Mailing Address - Street 2:
Mailing Address - City:ALTONA
Mailing Address - State:NY
Mailing Address - Zip Code:12910-2402
Mailing Address - Country:US
Mailing Address - Phone:518-204-4112
Mailing Address - Fax:
Practice Address - Street 1:16 DEGRANDPRE WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6451
Practice Address - Country:US
Practice Address - Phone:518-561-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-21
Last Update Date:2015-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist