Provider Demographics
NPI:1164044798
Name:VERNON STEWART, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:VERNON STEWART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:VERNON BOLTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:6791 E MOUNT VERNON CT
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-4034
Mailing Address - Country:US
Mailing Address - Phone:847-271-8462
Mailing Address - Fax:
Practice Address - Street 1:6791 E MOUNT VERNON CT
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-4034
Practice Address - Country:US
Practice Address - Phone:847-271-8462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009861101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty