Provider Demographics
NPI:1437472818
Name:BERVEN, PAMELA LOU
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:LOU
Last Name:BERVEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 PIKE AVE
Mailing Address - Street 2:A103
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99354-2281
Mailing Address - Country:US
Mailing Address - Phone:509-438-3252
Mailing Address - Fax:
Practice Address - Street 1:1780 PIKE AVE
Practice Address - Street 2:A103
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99354-2281
Practice Address - Country:US
Practice Address - Phone:509-438-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007211225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00007211OtherLICENSED MASSAGE THERAPIST