Provider Demographics
NPI:1073761631
Name:BECKER, PAMELA DOREEN (MA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DOREEN
Last Name:BECKER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 CONNECTICUT AVE S STE 105
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2479
Mailing Address - Country:US
Mailing Address - Phone:320-316-0288
Mailing Address - Fax:
Practice Address - Street 1:2351 CONNECTICUT AVE S STE 105
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2479
Practice Address - Country:US
Practice Address - Phone:320-316-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1963106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1073761631Medicaid