Basic Information
Provider Information | |||||||||
NPI: | 1831386051 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAGUE | ||||||||
FirstName: | PAMELA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WOCKNER | ||||||||
OtherFirstName: | PAMELA | ||||||||
OtherMiddleName: | S | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 285 BIELBY RD | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEBURG | ||||||||
State: | IN | ||||||||
PostalCode: | 470251055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8125371302 | ||||||||
FaxNumber: | 8125375219 | ||||||||
Practice Location | |||||||||
Address1: | 285 BIELBY RD | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEBURG | ||||||||
State: | IN | ||||||||
PostalCode: | 470251055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8125371302 | ||||||||
FaxNumber: | 8125375219 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2007 | ||||||||
LastUpdateDate: | 10/02/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 33004969A | IN | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 33004969A | 01 | IN | STATE LICENSE NUMBER | OTHER |