Provider Demographics
NPI:1508168477
Name:KOSTECKI, PAMELA ANNETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANNETTE
Last Name:KOSTECKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N OTTAWA ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-4006
Mailing Address - Country:US
Mailing Address - Phone:815-724-1156
Mailing Address - Fax:815-723-3452
Practice Address - Street 1:203 N OTTAWA ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-4006
Practice Address - Country:US
Practice Address - Phone:815-724-1156
Practice Address - Fax:815-723-3452
Is Sole Proprietor?:No
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0123891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932230OtherBLUE CROSS BLUE SHIELD
ILY05918Medicare UPIN