Provider Demographics
NPI:1215309208
Name:STEWART, PAMELA ANTOINETTE
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANTOINETTE
Last Name:STEWART
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 1:77 N HOLLISTON AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1944
Mailing Address - Country:US
Mailing Address - Phone:626-616-2962
Mailing Address - Fax:
Practice Address - Street 1:77 N HOLLISTON AVE
Practice Address - Street 2:APT 4
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1944
Practice Address - Country:US
Practice Address - Phone:626-616-2962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA628OtherCERTIFIED OCCUPATIONAL THERAPY ASSISTANT