Provider Demographics
NPI:1407933005
Name:PINE, PAMELA SUE (PHD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:PINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9735 WILSHIRE BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-2102
Mailing Address - Country:US
Mailing Address - Phone:310-275-1867
Mailing Address - Fax:310-275-4838
Practice Address - Street 1:9735 WILSHIRE BLVD STE 212
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-2102
Practice Address - Country:US
Practice Address - Phone:310-275-1867
Practice Address - Fax:310-275-4838
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16970103TA0400X, 103TC0700X, 103TF0200X, 103TP0814X, 103TP2701X, 103T00000X
CAPSY6970103T00000X
CAMFT17040106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA202957000OtherDEPT OF LABOR
CA710955581OtherBLUE CROSS
160373OtherVALUEOPTIONS