Provider Demographics
NPI:1104205681
Name:BOURDGANIS, PAM SEILER (LBSW, QIDP)
Entity Type:Individual
Prefix:MRS
First Name:PAM
Middle Name:SEILER
Last Name:BOURDGANIS
Suffix:
Gender:F
Credentials:LBSW, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19316 FAIRLANE CT
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-4056
Mailing Address - Country:US
Mailing Address - Phone:248-921-6210
Mailing Address - Fax:
Practice Address - Street 1:19316 FAIRLANE CT
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-4056
Practice Address - Country:US
Practice Address - Phone:248-921-6210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802072956171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator