Provider Demographics
NPI:1477050888
Name:DECOLO, PAMELA STUBBS
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:STUBBS
Last Name:DECOLO
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 1:15 CAMDEN RD
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02466-1503
Mailing Address - Country:US
Mailing Address - Phone:617-244-1710
Mailing Address - Fax:
Practice Address - Street 1:1430 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1623
Practice Address - Country:US
Practice Address - Phone:781-647-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10308011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical