Provider Demographics
NPI:1316961980
Name:PARK, PAMELA (OTR)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 OLD LEE HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-1806
Mailing Address - Country:US
Mailing Address - Phone:703-246-7165
Mailing Address - Fax:
Practice Address - Street 1:3750 OLD LEE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-1806
Practice Address - Country:US
Practice Address - Phone:703-246-7165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119001243225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA07182006186586Medicaid