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General NPI Number Information
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NPI Number | 1275810327
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Entity Type | Individual
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Provider Name | PAMELA KONSTANTINA PETRUSHESKY SLP
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Gender | Female
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Dates
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Enumeration Date | 11/03/2011
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Last Update Date | 11/03/2011
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Provider Practice Location Address
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Address Line | 2486 MAIN RD
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City | EAST PEMBROKE
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State | NY
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Zip | 14056
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Country | US
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Telephone | 585-599-4525
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Fax |
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Provider Business Mailing Address
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Address Line | 34 RUNNING BROOK DR
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City | LANCASTER
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State | NY
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Zip | 14086-3309
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Country | US
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Telephone | 716-668-5756
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 005729-1
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License Number State | NY
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