Provider Demographics
NPI:1407001357
Name:WATERMAN, PAMELA SUE (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 E WOOD ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523-1155
Mailing Address - Country:US
Mailing Address - Phone:217-425-9931
Mailing Address - Fax:217-425-9701
Practice Address - Street 1:720 E. WOOD ST.
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523
Practice Address - Country:US
Practice Address - Phone:217-425-9931
Practice Address - Fax:217-425-9701
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006107101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional