Provider Demographics
NPI:1407070980
Name:RISLEY, PAMELA ANNE (MSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANNE
Last Name:RISLEY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 LA PALOMA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3434
Mailing Address - Country:US
Mailing Address - Phone:505-672-9710
Mailing Address - Fax:
Practice Address - Street 1:127 EASTGATE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3300
Practice Address - Country:US
Practice Address - Phone:505-662-5717
Practice Address - Fax:505-662-5717
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 055661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95321781Medicaid
NM00JN33OtherMESA BLUE CROSS BLUE SHI
NM550010004361OtherPACIFICARE BEH HEALTH