Basic Information
| Provider Information | |||||||||
| NPI: | 1396024352 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | PAMALA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JUKA WILSON | ||||||||
| OtherFirstName: | PAMALA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 585 JEWETT RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488548729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176765405 | ||||||||
| FaxNumber: | 5176765460 | ||||||||
| Practice Location | |||||||||
| Address1: | 2702 FLUSHING RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485044534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104245998 | ||||||||
| FaxNumber: | 8104246347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401012506 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.