Basic Information
| Provider Information | |||||||||
| NPI: | 1407384266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUYER | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICDC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6209 STORER AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441025522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166511450 | ||||||||
| FaxNumber: | 2166514351 | ||||||||
| Practice Location | |||||||||
| Address1: | 6209 STORER AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441025522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166511450 | ||||||||
| FaxNumber: | 2166514351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 101YA0400X | 021225 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.