Provider Demographics
NPI:1285996173
Name:WITTENBERG, PAMELA ANN (MA)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:ANN
Last Name:WITTENBERG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 BLANK LN
Mailing Address - Street 2:
Mailing Address - City:WATER MILL
Mailing Address - State:NY
Mailing Address - Zip Code:11976-2136
Mailing Address - Country:US
Mailing Address - Phone:631-726-5029
Mailing Address - Fax:
Practice Address - Street 1:472 BLANK LN
Practice Address - Street 2:
Practice Address - City:WATER MILL
Practice Address - State:NY
Practice Address - Zip Code:11976-2136
Practice Address - Country:US
Practice Address - Phone:631-726-5029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY611681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1265562979OtherINDIVIDUAL SPECIAL INSTRUCTION PROVIDER
NY1265562979OtherONGOING SERVICE COORDINATOR