Provider Demographics
NPI:1407346125
Name:MARTIN, PAMELA GILLIAM (MA)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:GILLIAM
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:PAMELA
Other - Middle Name:ANN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3339 HOLMES AVENUE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408
Mailing Address - Country:US
Mailing Address - Phone:612-386-1521
Mailing Address - Fax:
Practice Address - Street 1:2324 UNIVERSITY AVE W STE 120
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1854
Practice Address - Country:US
Practice Address - Phone:651-644-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health