Healthcare Provider Details

I. General information

NPI: 1629387188
Provider Name (Legal Business Name): PAMELA SALLADE-BARDENSHTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 STONEHEDGES CT
BLOOMINGTON IL
61705-6306
US

IV. Provider business mailing address

1 STONEHEDGES CT
BLOOMINGTON IL
61705-6306
US

V. Phone/Fax

Practice location:
  • Phone: 309-242-5295
  • Fax:
Mailing address:
  • Phone: 309-242-5295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057000472
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: