Basic Information
| Provider Information | |||||||||
| NPI: | 1053337592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSTIN | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | DEMOSTHENES | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW, CP CAC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 SAPPHIRE CT | ||||||||
| Address2: | STE 110 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278349079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307561 | ||||||||
| FaxNumber: | 2524130932 | ||||||||
| Practice Location | |||||||||
| Address1: | WIESBADEN ARMY SUBSTANCE ABUSE PROGRAM | ||||||||
| Address2: | UNIT 29623 | ||||||||
| City: | APO | ||||||||
| State: | AE | ||||||||
| PostalCode: | 09096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 496117051710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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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 | 1041C0700X | C006055 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 06223 | SC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 64648 | SC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | C006055 | 01 | NC | NC BOARD OF SOCIAL WORK | OTHER | 06223 | 01 | SC | SC BOARD OF SOCIAL WORK | OTHER |