Provider Demographics
NPI:1174656409
Name:PATER-ENNIS, PAMELA J (LCSW,MDIV, PHD)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:J
Last Name:PATER-ENNIS
Suffix:
Gender:F
Credentials:LCSW,MDIV, PHD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:P
Other - Last Name:ENNIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, MDIV, PHD
Mailing Address - Street 1:114 BROOKVIEW TERRACE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-4504
Mailing Address - Country:US
Mailing Address - Phone:201-962-6443
Mailing Address - Fax:201-541-8100
Practice Address - Street 1:114 BROOKVIEW TER
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-3100
Practice Address - Country:US
Practice Address - Phone:201-962-6443
Practice Address - Fax:201-541-8100
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
NYR042224-11041C0700X
NJ44SC053391001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52171CMedicare ID - Type UnspecifiedSOCIAL WORK