Provider Demographics
NPI:1003359027
Name:CRISMON, PAMELA ELAINE (LPC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ELAINE
Last Name:CRISMON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MEDICAL DR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3426
Mailing Address - Country:US
Mailing Address - Phone:636-327-1183
Mailing Address - Fax:
Practice Address - Street 1:600 MEDICAL DR
Practice Address - Street 2:SUITE 109
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3426
Practice Address - Country:US
Practice Address - Phone:636-327-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008011076101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health