Provider Demographics
NPI:1083835250
Name:WIEBELHAUS, PAM (MS, LPC, LAC)
Entity Type:Individual
Prefix:MS
First Name:PAM
Middle Name:
Last Name:WIEBELHAUS
Suffix:
Gender:F
Credentials:MS, LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 N UNION BLVD STE 145
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3894
Mailing Address - Country:US
Mailing Address - Phone:719-344-2209
Mailing Address - Fax:877-343-0846
Practice Address - Street 1:7610 N UNION BLVD STE 145
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3894
Practice Address - Country:US
Practice Address - Phone:719-344-2209
Practice Address - Fax:877-343-0846
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0427101YA0400X
COLPC 2060101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO136998Medicaid