Provider Demographics
NPI:1114116100
Name:LIGHTLE, PAMELAKAY (MSE, PLPC)
Entity Type:Individual
Prefix:MRS
First Name:PAMELAKAY
Middle Name:
Last Name:LIGHTLE
Suffix:
Gender:F
Credentials:MSE, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 S 36TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-5924
Mailing Address - Country:US
Mailing Address - Phone:217-224-6300
Mailing Address - Fax:217-224-4329
Practice Address - Street 1:8965 HIGHWAY 36
Practice Address - Street 2:SUITE F
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6739
Practice Address - Country:US
Practice Address - Phone:573-221-7027
Practice Address - Fax:573-221-7028
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006025673101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496264706Medicaid