Provider Demographics
NPI:1275076978
Name:KIPP, PAMELA (BA)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:KIPP
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:ANN-KIPP
Other - Last Name:WEMTZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:3132 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4421
Mailing Address - Country:US
Mailing Address - Phone:619-683-3100
Mailing Address - Fax:
Practice Address - Street 1:3132 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4421
Practice Address - Country:US
Practice Address - Phone:619-683-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst