Provider Demographics
NPI:1679696496
Name:MARK, PAMELA A (PSYD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:MARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 E ROBINSON ST
Mailing Address - Street 2:STE 103
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-2040
Mailing Address - Country:US
Mailing Address - Phone:407-697-7173
Mailing Address - Fax:
Practice Address - Street 1:605 E ROBINSON ST
Practice Address - Street 2:STE 103
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-2040
Practice Address - Country:US
Practice Address - Phone:407-697-7173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6747103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73070Medicare PIN