Provider Demographics
NPI:1235534231
Name:CONNELLY-CASTLE, PAMELA (BA/BS)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CONNELLY-CASTLE
Suffix:
Gender:F
Credentials:BA/BS
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:CONNELLY-CASTLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA/BS
Mailing Address - Street 1:2180 E MOWREY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46725-7611
Mailing Address - Country:US
Mailing Address - Phone:260-705-7513
Mailing Address - Fax:
Practice Address - Street 1:2180 E MOWREY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-7611
Practice Address - Country:US
Practice Address - Phone:260-705-7513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201037870AOtherMEDICAID LPI