Basic Information
| Provider Information | |||||||||
| NPI: | 1740376532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BLACKWELL | ||||||||
| OtherFirstName: | PAM | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.F.T. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 162 GROVE ST STE J | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935142652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | 7608733277 | ||||||||
| Practice Location | |||||||||
| Address1: | 162 GROVE ST STE J | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935142652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | 7608733277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 106H00000X | 19310 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.