Provider Demographics
NPI:1326123225
Name:WALLEN, PAMELA RENNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:RENNE
Last Name:WALLEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3512
Mailing Address - Country:US
Mailing Address - Phone:573-760-1365
Mailing Address - Fax:573-760-0354
Practice Address - Street 1:1580 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3512
Practice Address - Country:US
Practice Address - Phone:573-760-1365
Practice Address - Fax:573-760-0354
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001013763103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO167106OtherBLUE CROSS BLUE SHIELD
MO495281511Medicaid
MO7994334OtherAETNA
MO614085OtherHEALTH LINK
MO167106OtherBLUE CROSS BLUE SHIELD