Provider Demographics
NPI:1356662449
Name:LEWIS, PAMELA J
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC, MHC
Mailing Address - Street 1:426 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3026
Mailing Address - Country:US
Mailing Address - Phone:904-284-6183
Mailing Address - Fax:
Practice Address - Street 1:1724 VILLAGE WAY
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5264
Practice Address - Country:US
Practice Address - Phone:904-269-0886
Practice Address - Fax:904-269-0499
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-12
Last Update Date:2010-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10100101YM0800X
TX17591101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional