Basic Information
| Provider Information | |||||||||
| NPI: | 1457423394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRANT | ||||||||
| FirstName: | PAMELA | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | RR# 2 BOX 172 | ||||||||
| Address2: | |||||||||
| City: | SUSQUEHANNA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077290044 | ||||||||
| FaxNumber: | 6077299994 | ||||||||
| Practice Location | |||||||||
| Address1: | 693 MAIN ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | NEW MILFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188347200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704652027 | ||||||||
| FaxNumber: | 5704652028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 006833 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225XH1200X | OC005531L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 02638439 | 05 | NY | MEDICAID |