Provider Demographics
NPI:1376610519
Name:SIDES, PAMELA PANCOAST (LPC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:PANCOAST
Last Name:SIDES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 LYNNDALE CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5463
Mailing Address - Country:US
Mailing Address - Phone:252-714-1566
Mailing Address - Fax:252-215-0057
Practice Address - Street 1:625 LYNNDALE CT
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5463
Practice Address - Country:US
Practice Address - Phone:252-714-1566
Practice Address - Fax:252-215-0057
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3088101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11613041OtherCAQH
NC2290515OtherCIGNA
NC6102827Medicaid
NC1413HOtherBCBS
NC187564OtherMEDCOST