Provider Demographics
NPI:1164508420
Name:WAITKUS, PAMELA ANN (LPC LMFT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANN
Last Name:WAITKUS
Suffix:
Gender:F
Credentials:LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 BOULEVARD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1341
Mailing Address - Country:US
Mailing Address - Phone:804-526-9885
Mailing Address - Fax:804-526-9884
Practice Address - Street 1:3606 BOULEVARD
Practice Address - Street 2:SUITE B
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1341
Practice Address - Country:US
Practice Address - Phone:804-526-9885
Practice Address - Fax:804-526-9884
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002551101YP2500X
VA0717000861106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist