Provider Demographics
NPI:1336491547
Name:DEST, PAMELA JEAN (INTERN)
Entity Type:Individual
Prefix:MISS
First Name:PAMELA
Middle Name:JEAN
Last Name:DEST
Suffix:
Gender:F
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 BRITTANY FARMS RD
Mailing Address - Street 2:APT 201
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1100
Mailing Address - Country:US
Mailing Address - Phone:860-483-0468
Mailing Address - Fax:
Practice Address - Street 1:34 MURRAY ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-1920
Practice Address - Country:US
Practice Address - Phone:203-756-8317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health