Healthcare Provider Details

I. General information

NPI: 1275810327
Provider Name (Legal Business Name): PAMELA KONSTANTINA PETRUSHESKY SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2486 MAIN RD
EAST PEMBROKE NY
14056
US

IV. Provider business mailing address

34 RUNNING BROOK DR
LANCASTER NY
14086-3309
US

V. Phone/Fax

Practice location:
  • Phone: 585-599-4525
  • Fax:
Mailing address:
  • Phone: 716-668-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number005729-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: